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Biolofica)
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5«nait

July, 1918.

Journal

Vol. XXXL

z^*^.

OF THE

Royal Army Medical Corps

EDITED BY

COLONEL SIR WILLIAM H. HORROCKS, K.C.M.G., C.B.

Assisted by
LIEUT. -COLONEL D. HARYEY, C.M.G., R.A.M.C.

ISSUED MONTHLY

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Advertisements.

Tested and Approved In Accordance vrlth L.O.B. Bequirements.

QAIYl

SYPHILIS

IS THE SAFEST OF

ALL ARSENICAL

COMPOUNDS IN

{Vide Presidential Address, British Pharmaceutical Conference, July 10, 1918.)

INTRAVENOUS. INTRAMUSCULAR.

(in Glucose).

Identical in Dose and Efficacy.

GALYL is as effective as SALVAR8AH or NEOSALYARSAN on Spirochaetes and

Trypanosomes, more rapid in action, and free from the neurotropic and congestive

action of these preparations.

60,000 Injections administered in Naval, Military, and General Hospitals,

have demonstrated that Galyl is efficient, rapid and vrell tolerated.

Intramuscular GALYL.

May 29th, 1918.
Dear Sivs,— T have ik»w given over 700 injections

I 'Iiitramns'-ular nalyU, with not one ill result. Tlie
i Cii ood— better, I consider.

' ti, nhstitute, and with the

; Gl! iinique is qnit-e simple.

I Vours truly, Dr. .

IntraYenons GALYL.

After 5,00fl Injections administered in one of our
Service Hospitals.

Staff Surgeon reports :
" No case has given the sHgiitest
cause for anxiety, and the clinical
results are very satisfactory."

MALARIA.

Doses: 0-10— 0-1.5— 0-20— 0-25— 0-30— 0-35— 040. FRAMBOSSIA.

Dosage :
4 per day

In metal box

containing

28 Spherules

INTRA-CELLULAtt

EXr-pA-'ill'Ji.Mi

Rhdantlne is the Entero-vaccino-therapeutic method in regard to Gonococcic Treat-
ment. Messrs. Lvuniere and Chrevotier had since 1913 been undertaking a fresh series
of experimental and clinical researches with reference to this subject. After considerable
difficulties in their endeavour to find a suitable medium for the cultivation of Neisser'a
diplococcus, they discovered one baaed on the wort of beer, which perfectly answered to
their requirements, and succeeded in preparing desiccated cultures, in vacuo, forming
a perfectly anhydrous and stable vaociual powder, containing about 500 millions bacilli
per milligramme. This is administered in beratinised spherules. The clinical effects
of Rheaiitine on gonorrhoea in its various stages and in the complications of the disease
are rapid, well marked and of the most satisfactory character.

Froni a paper read beforr. the Therajitutical Society of Paris (14 Juiu, 1916) :—

. . . " Under the microscope these successive changes are demonstrat«d in equally definite
stages ; whatever may have been the dui-ation of the disease, the characteristics of the pus become
rapidly nioditied ; after two or three days' treatment the gonococcns, first intracellular, becomes
exterior ; it ceases to act as a parasite on the polynuclear leucocytes and the large epithelial cells
— one then finds thara disseminated outride the leucocytes.

"Finally, some days later, if the administration of Bheantine is continned, the condition
undergoes still further change, the gonococci become agglutinated, arranged in a mass, and
finally bacteriolysed."

These clinical and bacteriological observations constitute irrefutable proof of the efficacy of
anti-gonococcic bacterio-therapy, by the gastro-intestinal tract.

The clinical reports of various doctors or noted by ourselves, show that antigonococcic bacterio-
therapeutics are capable of giving highly satisfactory results, both in acute and chronic forms of
urethral gonorrhoea and also in the various infectious complications due to Neisser's bacillus.
Literature and Clinioal Reports on Jieqxiest.

The Ang^lo-French Drug Co., Ltd., Gamage Building, Holborn, London, E.G.

Telephone: HolbornlSll. Telegranu : "AMPS&LVAS."

West £.><d Depot : MODERK PHARHACALS, 18, Mortimer St., W. 1. Telephone : Museum 564.

Advertisements.

ASH'S

"ANTIPAIN"

The Local Anaesthetic par excellence which contains slightly less than 1 per
cent. (0.972) Cocaine Hydrochloride with other essential ingredients.

We are now in possession of a Special Permit issued by the Secretary of
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Supplied in 2-oz. Bronvn Glass Stoppered Bottles.
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5-12, Broad Street, Golden Square, London, 'W.l.

ESTABIilSHED 1820.

LISTERINE

is a very successful

SURGICAL DRESSING.

An American Surgeon, of wide experience, in a paper entitled
"Wet Antiseptic Dressings," says:

" I am absolutely confident any wound, treated by the method I
describe, within a few hours of infliction, will never suppurate ; it will
control infections and its adoption would save thousands of lives." (Copy of
paper may be had upon request.)

Listerine is composed of volatile and non-volatile antiseptics. Its
employment affords prolonged and trustworthy antiseptic influence
without harmful effect upon healing tissue.

LAMBERT PHARMACAL COMPANY

2I0I Locust Street St. Louis, Mo., U.S.A.

British Agents: S. Maw, Son Si Sons. 7, Aldersgate St., London, E.C. 1.

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Copy of Bo.dei-io:ogUf!i Reoort u ad Fuii 2'art,rH!ars f,n,a the >ui, ihinufoAturers-

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IX.

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XI.

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COPVRIGHT

Fac Arst matter

Volume XXXI. July, 1918. No. 1.

Journal

of tfje

©liatnal Communications.

TOXIC ACTION OF CARBONIC AND OTHER WEAK ACIDS QN

THE MENINGOCOCCUS.

By J. A. SHAW-IVLiCKEN2IE, M.D.Lond.

In attempting to discover an effective method of direct antiseptic
treatment of cerebrospinal meningitis, it would seem advisable, when one
considers the delicate nature and fundamental physiological importance of
the nervous structures involved, to employ, as the basis of the antiseptic
fluid in view, a solution as uninjurious as possible to mammalian living
tissues. Ringer showed long ago that the tissues of cold-blooded animals
are capable of long survival, if instead of perfusing or bathing them with
0*6 per cent NaCl solution, regarded up till then as the physiological
solution par. excellence, a solution containing in addition to the sodium
chloride, physiological amounts of calcium and potassium salts and a trace
of sodium bicarbonate were employed. Many years afterwards Locke [1]
succeeded in extending this line of work to mammalian tissues, and showed
that a Ringer's solution of modified composition and containing in addition
sufficient oxygen and a physiological percentage of glucose was capable of
sustaining the activity of the excised mammalian heart for long periods.
The power of conserving the vital activities of the mammalian tissues in
contact with the Ringer-Locke fluid has since been abundantly confirmed
by various workers in the case of many different organs. It has been
pointed out, too, by Professor Halliburton [2] that the cerebrospinal fluid
itself is in its composition to all intents and purposes nothing but a Rinn-er-
Locke fluid of physiological origin. We have, therefore, abundant grounds
for taking as the basis of any antiseptic solution with which it is proposed
to treat the nervous system the Ringer-Locke fluid, in the hope that at
any rate this will have no special deleterious effect of its own, and that we
shall have only to fear such from the antiseptic agent we add to it. It
1

2 Toxic Action of Carbonic Acid on the Meningococcus

will be better too, if in all probability, instead of an antiseptic foreign to
the body, we can find a physiological antiseptic agent, produced by an
exaggeration or diminution of the physiological factors involved. From
this general point of view the work described in the following has been
undertaken.

I was led to this inquiry by my previous work on the toxic action of
copper compounds of amino-acids and in particular copper-alanine on
protozoa [3]. For, in the early part of last year, in some preliminary
experiments, the opportunity for which was kindly afforded me by
Professor E.T. Hewlett in the Bacteriological Laboratory, King's College,
a toxic action of copper-alanine (one part in 100,000 of water) was found
on the meningococcus also, on thirty minutes' exposure.

In further experiments carried out in association with Lieutenant-
Colonel Mervyn Gordon and Major Hine, at the Central Cerebrospinal
Laboratory, Royal Army Medical College, it was shown that the meningo-
coccus did not survive in concentrations of copper-alanine 1 in 1,000 in
sodium chloride solution, on twenty minutes' exposure, but in less con-
centration or in broth or serum, no toxic effect was observed in this time
limit. Experiments were also made with the copper-alanine in Ringer-
Locke solution. A somewhat more toxic effect was witnessed, as in this
case the meningococcus did not survive in 1 in 10,000 copper-alanine
on twenty minutes' exposure. No toxic effect was observed on five or
ten minutes' exposure, and as for purposes of local treatment, intrathecal
or naso-pharyngeal, a short time limit is obviously essential, the above
results did not indicate any special advantage in the employment of copper-
alanine as a bactericide in the treatment of cerebrospinal meningitis.
Nor could the solutions of 1 in 10,000 in Ringer-Locke fluid be regarded as
suitable for intrathecal use without fear of injury to the delicate tissues of
the central nervous system.

In these experiments, however, it was noticed that in two out of three
controls in 0'85 per cent sodium chloride solution alone, the meningo-
coccus survived. On the other hand, the meningococcus had not survived
in all three controls in Ringer-Locke solution alone. In all these cases
the control solutions had been inoculated at the commencement of the
series, and planted out in the usual way at the end — in each case the
exposure having been forty-five minutes at 37° C.

This unexpected observation in the case of Ringer-Locke solution
opened up therefore a further line of inquiry. For, if it held good that
Locke's modification of Ringer's fluid, corresponding in its salt constituents
to the natural fluids of the body, possessed in addition bactericidal properties
towards meningococcus, obviously the value of this solution for irrigation
purposes and intrathecal use would be still further evident.

Investigation has therefore been carried out by me in this direction in
the Bacteriological Laboratory, King's College, with the assistance of
Mr. F. Welch.

/. A. Shaw-Mackenzie 3

Technique.

The composition of the Ringer-Locke solution used was NaCl, 09 per
cent ; KCl, 0-042 per cent ; CaCl., (anhydrous), 0*024 per cent ; dextrose,
O'l per cent ; NaHCO^, 002 per cent. The water employed was distilled
in glass. The NaHCO^ is added last to the remaining constituents after
their previous sterilization. The NaHCOg itself cannot be heated to
ensure sterilization, but in these experiments practically this has proved
negligible. Five cubic centimetres of distilled water was added to a twenty-
four-hour culture on trypagar slope of an isolated strain of meningococcus
(Foster II) used throughout, forming a milky suspension (approximately
5,000 million meningococci to one cubic centimetre). Of this, in earlier
experiments, 0*1 cubic centimetre was added to 10 cubic centimetres of
the respective test solutions in sterile test tubes, and also to the same
amounts of water, 0*85 to 0*9 per cent sodium chloride solution, and of
trypsin broth ; these latter were for control purposes ; in subsequent
experiments, in order to ensure greater uniformity in results, 0*2 cubic
centimetre of the meningococcal suspension was taken as the inoculating
dose. After five, twenty, and sixty minutes' exposure of the meningococcus
in suspension to the various solutions kept at 37° C, the test tubes were
well shaken and a three-millimetre loopful of each solution was planted out
on trypagar slopes. These were then incubated at 3T C, and the results
read off in twenty-four and forty-eight hours. The forty-eight hours'
incubation is necessary as in many instances the twenty-four hours'
incubation proved insufficient, and the result, therefore, at that period is
unreliable. Either the subcultures of meningococcus showed growth or
not, and the result was charted as -}- or — ; even single colonies were
marked +.

The Behaviour of the Meningococcus in Ringer-Locke Solution,
AND the Action of its Individual Constituents.

At first, using 0*1 cubic centimetre of meningococcal suspension as the
inoculating dose, as previously employed, two out of three separate experi-
ments showed that the meningococcus did not survive on sixty minutes'
exposure to Ringer-Locke solution, thus appearing to confirm the original
results. Controls in water and in 0*85 and 0*9 per cent sodium chloride solu-
tion survived. The action therefore of the individual constituents of Rin^^er
and of Ringer-Locke solutions was investigated.

Water. — In water distilled in glass, as well as in ordinary distilled
water and in tap water, the meningococcus was shown to survive on five,
twenty, and sixty minutes' exposure.

Pure Sodium Chloride 0'8o and 0*9 per cent solutions. The survival of
the meningococcus in these solutions has almost invariably been evident
on five, twenty and sixty minutes' exposure at 37° C, and planting out, with
incubation for twenty-four and forty-eight hours at 37° C. Since the

4 Toxic Action of Carbonic Acid on the Meningococcus ■

completion of my experiments my attention has been directed to the work
of Flexner [4] and of Shearer [5] , both of whom conclude that physio-
logical solutions of sodium chloride have a destructive or toxic action on
the meningococcus. The discrepancy between their and my results may
be explained in part by the different conditions of experiment. In my
experiments, I have confined myself to a short time limit of exposure,
whereas Flexner's results apparently refer to comparatively long periods
of exposure, and Shearer's to an exposure of seventy-five minutes. In a
few experiments which I have since made, survival of the meningococcus
has been evident on exposures for two hours, followed by forty-eight hours'
incubation. Shearer notes, however, that freshly isolated meningococci
are more vulnerable to the action of sodium chloride than old laboratory
cultures ; the former seldom resist the action of 0"85 per cent pure
^sodium chloride for more than twenty minutes, though the latter could
sometimes resist the action for three to four hours. It may be that
a difference in results is due to the salt itself employed. Throughout
my experiments I was using " pure sodium chloride," but quite recently
coming towards the end of this particular stock bottle, I started on
another. The meningococcal controls in this sodium chloride solution did
not survive as usual (and the results in several sets of experiments, in
consequence, were discarded as valueless). The experiments had been
carried out precisely in the same way as before except in the alteration of
the salt employed. On reverting to the first stock bottle, the meningo-
coccus again survived. Both specimens of the sodium chloride were
Kahlbaum's "guaranteed pure for analysis." '

Calcium Chloride, Potassium Chloride, and Dextrose respectively in
0*85 and 0'9 per cent sodium chloride solution have each been favourable
to the survival of the meningococcus in my experiments.

Sodium Bicarbonate. — Repeated experiments showed that the meningo-
coccus did not survive on sixty minutes' exposure to sodium bicarbonate
0"02 to 0*04 per cent in sodium chloride solution. From this it was
inferred that the injurious effects on the meningococcus in Einger-Locke
solution were due to the sodium bicarbonate. Repetition, however, of
my previous experiments with Ringer-Locke solution, using 0"! cubic
centimetre of the suspension as the inoculating dose, failed to confirm the
earlier results, and no difference was observed in the Ringer-Locke solution
with or without the sodium bicarbonate. It is difficult to explain these
contradictory results. It may, however, be mentioned that the Ringer-
Locke solution employed in the earlier experiments was stock solution in

* Dr. Locke informs me that a similar variation in the behaviour of " chemically pure "
sodium chloride from different sources in physiological solutions, was observed by him in
•conjunction with Dr. Eosenheim in 1903. Certain specimens give solutions which fail to
keep the mammalian heart alive beyond two or three hours, and prevent it showing any
improvement with dextrose.

J. A. Shaw-Mackenzie 5

which a commercial sodium chloride had been used which is no longer
obtainable. It is possible this was of a toxic nature. It became of
interest to ascertain the effect of increasing the percentage amount of
sodium bicarbonate ; but with one per cent and two per cent in Einger-
Locke solution, the meningococcus continued to survive. Not only this,
but when sodium chloride solution was used, the addition of one per cent
sodium bicarbonate exerted no greater effect than that of 0-02 per cent had
done, while even in the two per cent solution the meningococcus survived.
Repetition of the experiment on several occasions confirmed this, at first
■ sight, paradoxical result. That increased percentages of NaHCO.5 had less
toxic effect could hardly be explained on the supposition that it acted by
virtue of its alkalinity or the relative concentration of the hydroxyl ions.
Considering the well-known facts so important for the theory of respira-
tion, of the dissociation of NaHCOg in solution into Na^COa and CO2,
it seemed not impossible that in dilute solutions with more complete
dissociation of the salt, the free CO.,, especially in the case of micro-
organisms, might be the active factor, and it became worth while to
investigate the action in physiological solution of CO., and other weak
acids on the meningococcus. In order to get rapidly a definite idea of
the effect of weak acids, experiments were made first with acetic acid.

Action of Acids.

Acetic Acid. — After exposure of the meningococcus 0*2 cubic centi-
metre suspension to ten cubic centimetres solutions of acetic acid of
strength respectively one per cent, 1 in 1,000, and 1 in 10,000 in 09 per
cent sodium chloride solution, a toxic effect was definitely shown. The
meningococcus survived only on five minutes' exposure in the 1 in 10,000
solution. Controls in sodium chloride solution and in water survived
as usual on the sixty minutes' exposure. Further experiments were
made with M/2500 acetic acid in 0*9 per cent sodium chloride solution
(corresponding roughly to 1 in 50,000). Survival of the meningococcus
was noted only on the five minutes' exposure ; longer than this proved
fatal.

Carhonic Acid. — Greater interest would seem to attach to the investiga-
tion of the effect of carbonic acid on the meningococcus. This is the
weakest physiological acid. It is constantly present in greater or less
amount in the blood and other body fluids. Its effects on living tissues
when not pushed to their limit are reversible. A concentration too great
to be borne by the central nervous system when perfused through its blood-
vessels would probably be successfully resisted if the solution was introduced
intrathecally, the persistence of the normal blood current in the -central
nervous system ensuring its survival.

Solutions of free carbonic acid were obtained by passing the washed
gas from a Kipp apparatus through the fluid used, for periods varying from

6 Toxic Action of Carhonic Acid on the Meningococcus

one to two minutes, some approximation to saturation being thus obtained.
In order, however, to obtain solutions containing known percentages of free
carbonic acid, the method employed was one suggested to me by Dr. F. S.
Locke which he had already made use of in order to prepare perfusion
fluids for the mammalian heart, of known free CO2 content. It possesses
also the advantage of giving a solution that can be sterilized by boiling.
The method depends on the conversion of sodium carbonate by sulphuric
acid into sodium sulphate, sodium bicarbonate and (in accordance with the
relative amounts of NagCOg and H.2SO4) the percentage of COo required.
Thus :—

2 NaoCOs + HoSO, = 2 NaHCOg + Na.,SO,
NaoCOs + H2SO, == CO2 + Na.SO, + H2O

It is obvious, therefore, that by the mixture of suitable amounts of equiva-
lent solutions of NasCOs and H2SO4 we can readily obtain within wide
limits the required percentages of NaHCOj and CO2. The Na2S04 formed
is for our purposes negligible. Ideal quantitative accuracy is not required
in the use of this method, as the small percentage of NaHCOg always left
in the final solutions acts as a " bufifer " preventing the presence of free
H2SO,.

It was found convenient to use \ normal solutions for the additions
necessary for the formation of the small amount of NaHCOg used. For
the further equal amounts of H2SO4 and of NaoCOg forming the required
percentage of COg, \ normal solutions were made use of. The following
solutions were investigated : —

Solution No.

Ringer-Locke

(without alkali

or dextrose)

XMHjSOi

N/4Na,CO, K/2H,SO^

N/2Na,0O3

Volume
per cent CO,

1
2
3

c.c.
50
50
50

c.c.
0-25
0-25
0-25

c.c.
0-5
0-5
0-5

c.c.

1
2
4

c.c.
1
2

11
22
44

The necessary amounts of H2SO4 can be added to the non-alkaline
Einger-Locke fluid, and the mixture sterilized. The Na-^COg solutions
can be separately sterilized, and added in the cold to the HgSO^ mixture.
Toxic effects on the meningococcus were found with Solutions 2 and 3,
but not with Solution 1.

Similar solutions were investigated also in which fifty cubic centimetres
sodium chloride solution were used in place of the Ringer-Locke solution.
With these a toxic effect was found with Solution 1.

The results, together with toxic effects obtained at the same time with
sterilized solutions of 0'9 per cent sodium chloride through which the CO2
gas itself had been passed,' are given in the following tables of two
experiments.

' (The supposed saturation with CO2 thus obtained may be assumed to have been any-
thing between sixty to eighty volumes per cent).

/. A. Shaw-MacJcenzie

A third experiment was made with similar results : 0'2 cubic centi-
metre meningococcal suspension was taken as usual, as the inoculating
dose to 10 cubic centimetres of each solution ; results with liinger-Locke
solution (0-02 per cent NaHCO.,) and with NallCOg (0-02 per cent) in
sodium chloride solution, obtained at the same time and under the same
conditions of experiment are given also, and in these 01 cubic centimetre
suspension was taken as the in'oculating dose as in the earlier experiments.

0)_
Exposure in minutes at 37" C.
Ringe'r-Locke solution COa (Solution 1) . .

,, ,, ,, (Solution 2) . .

,, ,, „ (Solution 3) ..

NaCl 0'9 per cent solution COj (Solution 1)
COj gas in 0-9 per cent NaCl solution
NaCl 0-9 per cent solution alone ..
Water (glass, distilled)

Broth -.

Meningococcal suspension at room temperature
Subculture +

(2)

Exposure in minutes at 37*' C.
Ringer-Locke solution COa (Solution 2) . .
,, ,, (Solutions) ..

NaCl 0*9 per cent solution CO^ (Solution 1)
COa gas in 0-9 per cent NaCl solution
Ringer-Locke solution (0'02 per cent NaHCO,)..
NaHCO, (0-02 per cent) in 0-9 per cent NaCl solution
NaCl 0-9 per cent solution alone . .
Water (glass, distilled)

Broth

Meningococcal suspension at room temperature
Subculture +

Forty-eiglit hours' incubation at 37" C.

at 37" C.

It will be seen from the above that Einger-Locke CO2 solution, sodium
chloride CO., solution, and sodium chloride solution, through which CO2
gas has been passed, respectively, exert a definite toxic effect on the
meningococcus. On the other hand, it will be seen that the meningococcus
survived in Einger-Locke solution (0*02 per cent NaHCOa), but did not
survive exposure of sixty minutes to NaHCOg (0'02 per cent) in sodium
chloride solution. Controls in sodium chloride solution alone, water, and
in broth, survived as usual.

Serum. — A destructive action by serum (guinea-pig) on meningococcus
has been shown by Flexner. In the following preliminary experiment a
rapid or increased toxic effect of serum through which CO2 has been passed
is shown. For this purpose fresh sterile serum (rabbit) was used. The
serum was sHghtly blood-stained ; 2*5 cubic centimetres of the serum so
treated and 2*5 cubic centimetres of the normal serum were inoculated with
005 cubic centimetre of meningococcal suspension ; the technique being
otherwise the same as described in previous experiments. A toxic action

8 Toxic Action of Carbonic Acid on the Meningococcus

of the serum (rabbit) control is not evident under the conditions of a short
time limit of exposure in my experiment. The effect of CO, gas in sodium
chloride solution was again examined (0'2 cubic centimetre suspension to
ten cubic centimetres solution), and the toxic action confirmed.

Forty -eight hours incubation at 37» C.

—

Exposure in minutes at 37° C . .

Serum COj gas

Serum alone

COj gas in 0-9 i^er cent NaCl solution

NaCl 0"9 per cent solution alone

Water (glass, distilled)

Meningococcal suspension at room temperature

Subculture +

Lactic Acid. — Next to carbonic the most important acid katabolite is
lactic acid. It is produced by many organisms, and it seemed of interest
to investigate its effect on the meningococcus which is known to ferment
dextrose. Sarcolactic acid has not so far been investigated. The phar-
macopoeial lactic acid was made use of. In M 2500 and M/5000 (in
0'9 per cent sodium chloride solution) it was found to exert a marked toxic
effect, showing survival of the meningococcus only on the five minutes'
exjiosure.

On the suggestion of Dr. 0. Rosenheim, an attempt has been made by ,
me to investigate the relationship which might exist between the toxic
effect of the above acid solutions and their hydrogen ion concentration.
A hydrogen ion concentration of Ph 7'02 represents absolute neutrality,
and Ph 7-35 near that of the blood [6] ; which reaction for cultural
purposes on nutrient media is also near the optimum for the growth of
most pathogenic organisms [7]. The hydrogen ion concentration of
cerebrospinal fluid (man) has been represented as Ph 8'1 when fresh, but,
on standing, it soon reaches Ph 9'25, attributed to the loss of carbonic
acid [8]. According to Hurwitz and Tranter [9] the Ph varies from
815 to 8'3, and cerebrospinal fluid is thus regarded by them as more
alkahne than blood. Milroy [10] has recently confirmed this, and points
out further that the Ph at low COo pressure is higher, or, in other words,
the alkalinity is greater than blood plasma.

For the above-mentioned purpose a series of Sorensen's standard mix-
tures of primary potassium phosphate and secondary sodium phosphate
were prepared. It was found that in a mixture of 9"75 cubic centimetres
M/15 primary phosphate and 0"25 cubic centimetre M 15 secondary phos-
phate, corresponding to a hydrogen ion concentration of Ph 5-3, the
meningococcus did not survive on sixty minutes' exposure. In primary
phosphate solution alone, corresponding to a hydrogen ion concentration
of Ph 4'5, the meningococcus failed to survive on twenty minutes'
exposure. I append a typical experiment, the technique employed being
the same as before.

J. A. Shatv- Mackenzie

Pliospliate mixtiirR

Methyl red

r> drops, 10 c.c.

colouration

(before
inoculation)

Toxic action— niinut«

■s

Primary c.c.

Secondary c.c.

3-0
7-0
9-75
10-0

7-0
30
0-25
00

Yellow

Faint pink . .
Pink . .

7-2
6-4
5-3
4-5

+
+
+
+

+
+
+

The toxic lactic and acetic acid solutions gave similar reactions, the Ph
in these cases ranging also between 4-5 and 5-3. The toxic concentra-
tion of CO, in Einger-Locke solution gave the same result. The much
weaker concentration of CO., (11 vols, per cent) (Solution 1) however, which
had been found toxic to the meningococcus in pure sodium chloride
solution, gave only a yellow colouration with the indicator indistinguishable
from that given by pure sodium chloride solution alone. In pure sodium
chloride solution therefore a much weaker hydrogen ion concentration due
to C0.2 is toxic to meningococcus than corresponds to Ph 4-5 to 5-3.
The indicators at my disposal did not permit of a more exact result than
this. It is, moreover, obvious that the hydrogen ion concentration of the
standard and other solutions is considerably lowered by the added menin-
gococcal suspension which by itself possesses a distinct alkahne reaction.
Further experiments in which the micro-organism itself is exposed directly
to the solutions, or cultured in nutrient media of known Ph, will be necessary
to determine the point at which a toxic action is exerted. It will be
necessary also to ascertain the hydrogen ion concentration of the cerebro-
spinal fluid itself in cerebrospinal meningitis.

In interpreting the results obtained with CO., regard must not be lost
of the fact that CO2 as. an acid occupies quite a special physiological
position as a general end product of vital chemical reactions. Increased
percentages of it, therefore, in physiological fluids might exert a specific
inhibitory effect on the vital activity of micro-organisms also, in addition to
its effect as an acid in increasing hydrogen ion concentration.

It would appear from the results of the investigation described above,
that local treatment of areas, intrathecal and naso-pharyngeal, infected with
meningococcus might be tried with Kinger-Locke fluid, or with sodium
chloride solutions, containing, as physiological antiseptics, physiologically
excessive amounts of carbonic or lactic acids.

Slater [11], Kideal [12], and others have described the bactericidal
action of CO., in solution on various pathogenic bacteria ; these, however,
differ considerably in their resistance to CO2. The local application of the
gas itself has also been described with sedative and beneficial effects in the
treatment of open wounds and ulcerations, as well as by rectal introduction
in cases of dysentery.

In extending this investigation I have found, in preliminary experi-

10 Toxic Action of Carbonic Acid on the Meningococcus

ments, that carbonic acid in sodium chloride solution exerts a rapid toxic
effect on the protozoon opalina ; also on Spirocliceta pallida. The possible
use of carbonic acid in syphilitic disease of the central nervous system, and
in the treatment of diseases due to protozoa, is thus suggested.

In conclusion, I desire to express my best thanks to Professor Halliburton
and to Professor Hewlett for the opportunity kindly afforded me in their
laboratories, and for much kind assistance throughout this work. To
Lieutenant-Colonel Gordon also my best thanks are due for his kind
assistance throughout, and supply of the necessary cultures and nutrient
media.

Conclusions.

(1) The meningococcus survives exposure to Einger-Locke solution.

(2) Sodium bicarbonate (0"02 per cent and 1 per cent) in sodium chloride
solution exerts a toxic effect on exposures of sixty minutes ; a 2 per cent
solution has no toxic effect.

(3) CO2 and other acids in small concentration exert a toxic effect.

(4) In Ringer-Locke solution containing free COo twenty-two vols,
per cent and upwards, the meningococcus does not survive exposure of
twenty minutes. In sodium chloride solution the toxic effect is more
marked.

(5) The toxic action of serum through which COo gas has been passed
is pronounced.

(6) Lactic and acetic acid in M/.5000 and M/2500 respectively (in
0"9 per cent sodium chloride solution) have a similar toxic action on the
meningococcus.

(7) The preliminary experiments on the hydrogen ion concentration
have not yielded sufficiently definite results to determine at what point the
toxic action is exerted, and do not exclude a specific action of its own on
the part of COo.^

(8) It is suggested that normal solutions containing increased amounts
of CO., or lactic acid may, as physiological antiseptics, be employed in the
local treatment of areas, intrathecal and naso-pharyngeal, infected with
meningococci, and that even the CO., normally occurring in the plasma
and body fluids may form part of the protective processes of the body.

(9) Preliminary experiments show that COo in sodium chloride solution

' Attention may here be drawn to the results of K. Taylor {Lancet, i, p. 294, 1917),
which I only became acquainted with after my own work was completed. He has investi-
gated the concentration of various acids inhibitory to bacterial growth. He does not
mention CO^, and regards his results as proving a specific action of acids without making
any reference to hydrogen ion concentration. It is worth while, however, pointing out
that if their correctness be assumed it is impossible to explain them in terms of the
hydrogen ion. The ratio of the concentration toxic for one organism (even when recalcu-
lated molecularly, taking, e.g., acetic and propionic acids) is inverted in the case of another
organism. This would nessitate the assumption of an inverse relation between molecular
concentration and hydrogen ion concentration in either one or other of the two acids.

J. A. Shaio-Machenzie 11

exerts a rapid toxic effect on the protozoon opalina ; and on S. pallida.
It is not impossible that CO.^ might also be made use of in syphilis of the
central nervous system, and in diseases due to protozoa.

REFERENCES.

[1] Locke, F. S. Centralh. f. Physiol., vol. x\v,^. Q>10, 1901 ; Locke, F. S. , and Rosenheim,
0., Joiirn. of Physiology, vol. xxxvi, p. 205, 1907.

[2] Halliburton, W. D. Proc. Roy. Soc. Med., vol. x (Section of Neurology), pp. 1 to 12, 191C.

[3] Shaw-Mackenzie, J. A. Proceedings Physiological Society (Journ. of Physiology, vol. li),
1917 ; Med. Press and Circ, vol. ii, p. 50, 1916.

[4] Flexneb, S. Journ. Expt. Med., vol. ix, 1907.

[5] Shearer, C. Proc. Roy. Soc, vol. Ixxxix, B., p. 440, 1917.

[6] Walpole, G. S. Biochem. Journ., vol. v, 1910-11; vol. viii, 1914.

[7] Cole, S. W., and Onslow, H. Lancet, vol. ii, p. 9, 1916.

[8] BisGAARD. Biochem. Zeitschr., vol. Iviii, p. 1, 1914.

[9] HuRwiTZ, S. H., and Tranter, C. L. Arch. Inter. Med., Chicago, vol. ivii, p. 32G, 1916.

[10] MiLBOY, J. H. Journ. of Physiology, vol. li, p. 259, 1917.

[11] Slater, C. Journ. Path, and Bad., vol. i, iv, p. 468, 1893.

[12] Rideal, S. "Disinfection and Disinfectants," p. 104, 1895.

THE SYMPTOMS OF ACUTE CEREBELLAR INJURIES
AS OBSERVED IN AA'ARFARE.

By Lieutenant-Colonel GORDON HOLMES.

Royal Army Medical Corps.

[Contiuued from page 570.)

Disturbances of Speech.

Apart from the oculomotor, the only cranial nerves of which the func-
tions are obviously affected by unilateral cerebellar lesions are those which
are concerned iri phonation and articulation.

Speech is abnormal in most cases in which the lesions are recent and
severe ; it is usually slow, drawling and monotonous, but at the same
time tends to be staccato and scanning. This gives it an almost typical
"sing-song " character and makes it indistinct and often difficult to under-
stand. In a few patients speech was in fact quite unintelligible for a time.
In many cases the utterance is remarkably irregular and jerky, and that of
many syllables, especially, as Marie has pointed out, of those that end
a sentence, tends to be explosive.

Phonation is as a rule more affected than articulation, though both
vowels and consonants are slurred and uttered unequally and irregularly.
All classes of consonants too are affected, but articulation sometimes has a
special nasal character and the labials particularly tend to be explosive.

Another striking feature is the apparent effort necessary to utter a
series of syllables or a sentence ; the attempt is associated with excessive
facial grimacing and speech has consequently a laboured character that
often recalls a pseudo-bulbar paresis. A few of the patients also showed a
tendency to burst into explosive and excessive laughter when amused.

These abnormal features subside as a rule rapidly, but in a few cases
the speech was not yet natural two or three months after the infliction of
the wound.

Beflexes

Striking alterations in the reflexes is not a prominent or very obvious
symptom in the clinical examination of patients with cerebellar lesions,
but they are frequently abnormal, or when the injury is unilateral they
may be unequal on the two sides. The change can be best studied in
the knee-jerks in cases in which the injuries are limited to one-half of the
cerebellum, but they can also be seen in the arm- and in the ankle-jerks.

When the knee-jerks are elicited as the patient either lies in bed or
sits with his legs hanging freely, that of the healthy side seems unaffected,
but the homolateral jerk is at first often feebler, less brisk and less easy to
elicit ; or a response may be obtained from one or two only of a series of

Gordon Holmes

Fig. 11. — Tracings of three knee-jerks of a normal man taken on a slowly revolving drum.
Kead from right to left. The slight secondary swing seen in these tracings does not occur in
many normal men.

Fig. 12.— Tracings of two knee-jerks of a man with a right-sided cerebellar lesion of eight
years' duration. Tracing is less reduced than that in fig. 11. Read from right to left.

14 The Symptoms of Acute Cerebellar Injuries

taps on the patellar tendon, though the range of the jerk is then generally
large and ample. In a few cases the jerks were wholly absent during the
acute stages of the illness, unless reinforcement was employed.

When the patellar tendon is tapped as the patient sits on a high
chair so that his legs are unsupported and can swing freely, the jerk of
his homolateral leg when compared with that of his other limb appears
less brisk, often slower, and it lacks that decisive, forcible character of
the normal knee-jerk, though its range may be as large or even greater.
Further, while the normal limb falls deliberately to its original position
and quickly comes to rest, that of the affected side often continues to
swing inertly to and fro for a time like a pendulum ; the jerk has
consequently the pendular character described by Andre-Thomas. This
feature can be seen by comparing fig. 11 and fig. 12.

But in order to study more fully this change in the reflex it is
necessary to record the movement of the leg on a more quickly moving

drum.^

By this means I found that though from unaided observation the
jerk was frequently described as slower or less brisk, there was no
increase in the latent period as recorded by the apparatus I have
employed. In several normal persons this, when measured from the
instant the tendon was struck to the commencement of the movement
of the leg, varied between 0*038 sec. and 0054 sec, being in the majority
0*043 sec, which agrees approximately with the latent time obtained in
man by Franz, by Guillain, Barre and Strohl and others by tambours
placed on the quadriceps extensor. In the patients with cerebellar
injuries in whom I have similarly recorded the jerk the latent period
always lay within the same limits ; in one man with a very severe lesion
it constantly approached the lower figure. The apparent slowness is
consequently not due to a delay in a response or to a slower move-
ment of the limb ; but it is probable the subjective interpretation of the
inertness in the swing of the leg.

But such tracings (figs. 14 and 15) show other important changes.
When that of a normal jerk is examined (fig. 13) it is obvious that
the fall of the leg is considerably slower than its rise, and the curve

' My records were obtained by attaching firmly to the leg, at a fixed distance below the
axis of rotation of the knee-joint, a properly shaped splint which carried a rod attached to it by
a joint at which only slight vertical movement was possible. This rod was connected by a ball-
and-socket joint with a longer bar which could move accurately and with a minimum of friction
through three guides in the plane of the movement of the leg : a suitable marker fixed to this
bar recorded the movement directly on a revolving drum. The moment of the tap on the
patellar tendon was registered by an electro-magnet, the circuit being closed when the metal
hammer, to which one terminal was connected, came in contact with a copper wire placed in
close contact with the skin over the patellar tendon. Time was recorded by a tuning-fork
of 128 vibrations per second (C).

Gordon Holmes

does not therefore correspond with the oscillations of a pendulum.
Evidently then a tonic contraction, or state of tone, in the extensor
muscles prevents the immediate fall of the normal leg to the abscissa.
This fact is already known from the records obtained by various
methods in experimental animals and in man. I have found the time

Fig. 13. — Tracings of the knee-jerks of two normal men recorded in a rapidly revolving
drum. Bead from right to left. Time by a tuning-fork of 128 vibrations per second. Reduced
to one half. >. •■ ,

Fig. 14.— Tracing of the right knee-jerk of a man who received a severe injury to the
right side of his cerebellum eight years previously. Read from right to left. Time by a
tuning-fork of 128 vibrations per second. Signal on the lowest line.

of the rise in relation to that of the fall in several controls to vary
between 1 to 1'2 and 1 to 2""2. In the curves obtained from the affected
limb in men with cerebellar injuries the fall to the abscissa is on the
other hand almost invariably more rapid than the rise (fig. 14) ; in the

The Sy7npto7Jis of Acute Cerebellar Injuries

cases in which I have measured it the relation of the duration of the rise
to that of the fall of the curve averaged 1 to 0'85. Here there is con-
sequently no evidence of tone or muscular contraction impeding or delay-
ing the fall of the limb under the influence of gravity, and the falling
limb acquires sufficient velocity to make it swing, provided its oscillations
are not resisted by the tone of the muscles that move the knee-joint.
These oscillations give regular curves which have all the features of those
of a pendulum ; and it can be easily ascertained that they are not associated
with any active contractions of the extensor or flexor muscles of the knee.

Pig. 15. — Tracing of the right knee-jerk of a man with an extensive injury of the right
side of his cerebellum, obtained ten weeks after the infliction of the wound. Read from right
to left. Time by a tuning-fork of 128 vibrations per second. Signal on the lowest line.

There is another feature in the knee-jerk of the affected side which can
be easily detected by careful observation. If the observer places one hand
across the hamstring tendons behind the normal knee he can generally feel
a brisk tightening of these tendons, due to contraction of the flexors of the
knee, at a very short interval of time after the patellar tendon has been
struck, providing that this produces a jerk of suflicient range. Palpation
of the flexor muscles shows that this tightening of the tendons is due to
their active contraction, and not merely to passive stretching by the exten-
sion of the knee. On the affected side, however, no such contraction of
the hamstrings can be felt, no matter in what position the knee is placed,
or how great the amplitude of the jerk may be. One result of this may be
seen if, while the two limbs are fully supported on the bed with the hips
and knees semiflexed and the thighs rotated outwards so that the heels are
at the same level, the patellar tendons are tapped in succession ; the foot of
the affected side is moved abruptly 'towards the bottom of the bed by
each jerk that is elicited, but it returns, or tends to return, immediately to

Gordon Holmes ' 17

its original position, while on the affected side the foot generally remains in
the position into which it has been moved by the contraction of the quadri-
ceps, and the knee can be in fact often fully extended by a series of taps on
the patellar tendon. This failure of the contraction of the hamstrings and
of the consequent pull back of the leg was present in all my cases of severe
injury, and its occurrence was repeatedly confirmed by independent wit-
nesses. It usually persists as long as there are obvious disturbances in the
movements of the limb ; it was very striking in a patient who had received
his injury eight years previously.

The ankle-jerk is less commonly abnormal, though when the knee-
jerk is depressed • or difficult to elicit this reflex is usually more so. In
five of my cases, however, in which there was no evidence of involve-
ment of the pyramidal tracts, a short ankle-clonus could be obtained on
the affected side ; it resembled that due to organic disease but did not
persist on continued pressure on the sole ; in fact, as a rule it consisted
of a few jerks only.

In many cases the flexor and extensor reflexes of the elbow were
less brisk than on the normal side. In these reflexes it is less easy to
detect a concomitant reflex contraction of the antagonists of the contract-
ing muscles, but when the forearm is allowed to hang unsupported it
frequently tends to swing in the pendular manner described by Andre-
Thomas, especially after the triceps-jerk has been elicited.

No difference in the superficial reflexes, the abdominal, cremasteric
and plantar, of the two sides could be detected in even the severest uni-
lateral lesion, and in every case they presented their normal characters.

Sensation.

Finally we have to consider the state of sensation in cerebellar lesions.
This is an interesting and important point, since Lussana regarded the
cerebellum as an organ of the " muscular sense," and Lewandowsky has
attributed many of the motor abnormalities to disturbance of muscle
sensibility, meaning thereby those sensations evoked in consciousness by
the state of contraction of the muscles, and by movement and the position
in space of different portions of the body.

I have, however, examined every modality of sensation in many cases
but have never found disturbance of any form, nor have I detected
any evidence that would point unequivocally to any alteration of it. No
matter how irregular the movements may be, or how far the affected limb
deviates from the point to which it should be moved, the patient always
has a full and accurate recognition of its position in space.

It is true that, as Luciani observed in animals, the withdrawal of a
limb that is pricked and the reaction to the prick, are occasionally less
brisk on the homolateral side w^hen the lesion is early and extensive, but

18 The Symptoms of Acute Cerebellar Injuries

no alteration in the threshold of, or diminution in the acuity to, tactile
and painful stimuli, or even subjective differences between the sensations
similarly evoked on the two sides, ever existed.

Lotmar has described a disturbance in the appreciation of weights by
the affected hand, and Maas and Goldstein. have supported his statements,
but in none of their three cases was a lesion limited to the cerebellum
demonstrated anatomically ; there was for instance a diffuse cysticercus
meningitis with hydrocephalus in Goldstein's patient. All three authors
base their conclusions on the fact that when weights were simultaneously
placed in his two hands the patient usually under-estimated that on
the affected side. I have investigated the appreciation of weights in
eleven cases with extensive unilateral lesions, and in some of them on
several occasions. In two no disturbance existed, but in the others it was
found that if while the arm was still asthenic identical weights were placed
in his two hands, his eyes being closed, the patient frequently did not
recognize that they were equal, and in almost every case stated that the
heavier was in the affected hand. When unequal weights in which the
difference was relatively small but appreciable, as 80 grm. and 100 grm.
or 200 grm. and 240 grm., were placed in his hands, his replies were correct
when the heavier lay on the affected palm, but often wrong when the
normal limb carried it. Consequently the ability to recognize the identity
or inequality of weights lifted simultaneously by the two hands was
affected. In all these cases the tendency was to call that on the affected
palm the heavier, except one man who at first occasionally described that
borne by this hand as lighter, though in all subsequent examinations when
the weights were equal or approximately so, that in the affected hand
seemed to him the greater. But obviously these observations cannot be
accepted as evidence of disturbance in the appreciation of weight, since
by every paretic limb weights are adjudged heavier than they actually are,
even though sensibility is unaffected. The greater effort which a patient
suffering from a unilateral cerebellar lesion must put into all attempts to
move the homolateral, limbs suggest strongly that he will necessarily over-
estimate, or estimate wrongly, the resistance which these movements
encounter. Whether any disturbance in the appreciation of weights
exists can be decided only by testing his ability to discriminate between
two weights within the normal threshold of difference which are placed
successively in this hand. This was done in all my eleven cases.
The difference-threshold for the unaffected hand was first carefully
ascertained and then a series of observations was made by placing the
same two weights in succession in the affected hand. By this method no
loss or defect in the appreciation of weights could be detected on either
side ; in one patient in fact the difference-threshold for the affected limb
was considerably smaller than in the other and in several normal persons

Gordon Holmes

who were tested at the same time, but this was explained by the fact that
he had been a mica dealer in Canada and accustomed since childhood to
" weigh " his wares in his left hand.

The following records, selected from a long series of observations which
were obtained nineteen days after the infliction of the wound, in a man
with an extensive lesion in the right half of his cerebellum, illustrate
these facts.

l{it,'lit hand

L.:"ft hand

200 grm.
200 „

Eight heavier

200 „
200 „
200 ,,

200 . ,,
200 „
200 ,,

Equal
Right heavier

200 ,,

200 „

150 ,,

200 „

150 ,,

200 „

Left heavier

200 ,,
200 ,,

150 ,,
150 „

Right heavier

150 „
150 „
200 ,,

200 ,,
200 ,,
150 ,,

Equal
Right heavier

J' M

But when the discrimination of weights was tested by placing two
weights successively in the one hand he gave the following replies : —

First weight

Second weight

Right hand

Left hand

100 grm.

80 grm.

Correct

100 ,

80 ,,

80 ,

100 ,

100 .

80 ,

100 ,

Equal

80 ,

100 ,

Correct

200 ,

150 ,

200 ,

150 ,

200 ,

150 ,

200 ,

150 ,

200 ,

'•

•'

We must therefore conclude that no form of sensation is disturbed
by cerebellar disease, and that though the patient often cannot compare
correctly weights placed at the same time in his two hands, this does
not depend directly on a disturbance of the faculty of appreciating and
discriminating weights.

All the evidence available from the careful investigation of sensibility
in cases of cerebellar lesions in man, in whom alone it can be properly
tested, shows conclusively that this organ is not concerned in the trans-

20 The Symptoms of Acute Cerebellar Injuries

mission, or in any modification or elaboration, of those afferent impulses
which give rise to conscious sensations.

Symptoms due to Lesions of the Vermis.

I have not yet seen a case in which a gunshot wound produced a
lesion limited to, or affecting mainly, the vermis of the cerebellum, though
this was undoubtedly involved in some of the unilateral and in most of the
bilateral injuries. Consequently the only conclusions on this point that
can be drawn from my material must be by comparison of the symptoms
in cases where one lateral lobe only was affected, with those present in
which the vermis also was injured. But unless the differences in the
symptoms of these two groups of cases are essentially distinct in one or
more particulars they cannot be forthwith regarded as indicating a special
physiological significance of the vermis, in view of the evidence of func-
tional localization in the cerebellum which has been brought forward
within recent years.

No essential difference can be detected when the symptoms due to
lesions strictly limited to one lateral lobe are compared with those of cases
in which the vermis is in addition involved, though in relation to the extent
of the damage the functional disturbances are somewhat greater and
recover less rapidly in the latter. The hypotonia, the abnormalities in
the voluntary movements of the limbs, the changes in the reflexes and the
nystagmus differ in no essential particular. Even the affection of gait and
of equilibration, which has been attributed by certain authors (Thomas,
Bothmann) to injury of the vermis, was not more pronounced when the
lesion included this, provided it did not extend sufficiently beyond the
middle line to produce symptoms in the opposite limbs. Two patients,
for instance, were under observation at the same time — in one a piece of
metal was removed from the lateral part of the left lateral lobe and con-
siderable destruction of tissue was found around it, while in the second
a large piece of shell-casing was extracted from deep in the mesial portion
of the right lateral lobe, practically through the paramedian fissure, and
a hernia which must have involved the vermis developed. The first man
attempted to walk fifty-eight days, and the second seventy-one days, after
the infliction of the injury and both succeeded equally well in walking and
in maintaining equilibrium. Further, there was no striking difference in
the characters of their gaits.

. When the injury extends so far over the middle line as to produce
also disturbances in the opposite limbs, gait and the maintenance of
equilibrium are naturally more seriously affected than when one side
only is involved.

The only special features of vermis affection that I have observed

Gordon Holmes 21

are greater disturbances of phonation and articulation, and more pro-
nounced tremor and greater difficulty in movement of the head and trunk
when the patient sits up, but even in these respects the symptoms do
not differ in nature from those produced by injury of both lateral lobes.

Symptoms op Bilateral Lesions of the Cerebellum.

In seven of my cases both sides of the cerebellum vjere. injured ; in
four the missiles had passed transversely or obliquely through the organ,
and in the other three there were tangential wounds which fractured and
depressed the occipital bone over it. Four of these patients died ; in one,
who had a penetrating wound, the posterior margins of both hemispheres
(lobi semilunares superior and inferior) were extensively damaged, but the
vermis was injured only superficially in the region on the declivum ; in
two cases there were depressed fractures with extensive haemorrhages and
superficial softenings in each lateral lobe, but the vermis escaped, while
in the fourth large portions of the. vermis and both lateral lobes were
destroyed by haemorrhage.

All these cases presented the same symptoms, and no striking
difference in nature could be detected between those in which the vermis
was involved and those in which it escaped. The limbs of both sides
were affected, but the disturbances of their movements differed in no
essential particular from those that result from unilateral lesions. Speech
was, however, very much disturbed ; it was slow, drawling and scanning,
and many syllables were uttered explosively. In two men it was so
indistinct as to be scarcely intelligible. The muscles of the trunk and
neck were very hypotonic, and the patients had difficulty in holding their
heads in any attitude if it was unsupported, and in sitting up if unaided.
The power of standing and walking could be observed in only one of these
patients, and in this man gait particularly was more severely affected
and the maintenance of equilibrium was more difficult, than in any case
with a purely unilateral lesion.

Symptoms produced by Lesions of the Cerebellar Nuclei.

It is extremely difficult to determine the part played by damage of the
nuclei in the symptomatology of these cerebellar lesions. Most pene-
trating gunshot wounds produce diffuse damage owing to the occurrence
of haemorrhage, oedema, softening and septic infection in the parts around
them, and the nuclei, the dentate in particular, are consequently very
.liable to be involved even when the wound of the cerebellum is relatively
superficial. On the other hand, when the nuclei are involved by such
injuries a portion of the cortex is also destroyed. We can consequently
decide which functional disturbances are associated with nuclear lesions
only by comparing the symptoms of superficial with those of deep wounds.

22 The Symptoms of Acute Cerebellar Injuries

In the first place we find that when the lesion is so superficial that
the nuclei cannot have been directly injured the symptoms are less
intense, less regular, and that they disappear much more rapidly. Several
such cases could be cited, but two will suffice.

Case 1. — Captain J. was wounded by a fragment of shell and became
immediately unconscious. When he was seen two days later a contused
penetrating wound was discovered three centimetres below and 22 centimetres to
the left of the inion. An X-ray photograph revealed a piece of shell-casing, which
had been driven through the skull, immediately under the wound. This and
pieces of depressed bone were removed next day ; a moderate area of destruction
existed in the cerebellum, but it seemed to be superficial. By measurement it
was found to correspond to the inner third of the lobus gracilis.

When he was first seen he presented all the symptoms of a severe cerebellar
injury. He had difificulty in deviating his eyes to the left, and when he brought
them over there was coarse, slow, regular and well-sustained nystagmus of large
amphtude; on looking to his right the movements were smaller, more rapid,
less regular and less well sustained. No' nystagmus occurred on looking down-
wards, though intermittent but fairly regular jerks developed when his eyes were
deviated upwards. His speech was slow, forced and scanning. His right Umbs
were unaffected, but the left were very hypotonic (all groups of muscles were
equally so), slow in all movements though not appreciably weak, and their
voluntary actions were disturbed by dysmetria, aimless deviations from the
direct fine of movement, dissociation into their component movements, and by
the occurrence of tremor towards the end of the action. Adiadochokinesis and
the rebound sign were marked in both arm and leg, and the left arm tended to
swing outwards when outstretched, and deviated outwards in Barany's pointing
test. Yet twenty-four days after the infliction of the wound this patient was
able to walk and use his hmbs quite well, and did not complain of any abnormal
symptom. On examination, however, it was found that some nystagmus still
developed when he looked fully to the left, hypotonia was still demonstrable in
the left arm, but this limb was now- only slightly slow and awkward in attempting
rapid alternate movements, and it still deviated outwards in the pointing test.

Case 2. — Private E. was wounded by a piece of shell-casing. He did not
become unconscious, but in attempting to stand up staggered like a drunken man
and fell to the left. When he arrived in a base hospital two days later a gutter
wound was found extending from the middle line two centimetres below the inion
towards the tip of the left mastoid. An X-ray examination showed fracturing
with depression of bone fragments to a depth of ll centimetres under the inner
portion of the wound. (This corresponded to the inner part of the lobus semi-
lunaris inferior and the upper margin of the lobus gracilis.) These fragments were
removed from the cerebellum and the wound was cleaned and drained.

When he entered hospital he had slow, coarse, sustained nystagmus in looking
to his left, fine and more rapid movements on deviation to the right, and hypo-
tonia, shght paresis and considerable ataxia of his left limbs. Twelve days later,
however, he could use his hmbs quite well, walk safely and on examination he
presented practically no abnormal symptoms.

Gordon Holmes 23

Such cases, in which the lesions were in all probability superficial,
suggest strongly that the ordinary symptoms of a destructive injury are
usually transient and recover rapidly if the deeper parts of the cerebellum,
and especially the nuclei, are not directly or indirectly involved. Certainly
such rapid improvement is never seen when the damage extends to the
neighbourhood of the central nuclei.

On the other hand, these superficial lesions produce all the symptoms
that are found when the nuclei too are injured, and they differ from these
only in degree.

Consequently, as far as my present observations permit, it must be
concluded that the effects of nuclear and of cortical lesions of the cere-
bellum differ in no essential particular, though those produced by the latter
are less intense, less regular, and recover more rapidly.

These statements can refer to the nucleus dentatus only, as I have
seen no case which survived long enough to permit thorough examination
in which there was reason to believe that the roof nuclei were involved.
If a wound extends so deep, it is very liable to open the fourth ventricle
and lead to an early fatal termination. The dentate nucleus, however, is
only two or three centimetres deep from the posterior surface of the
cerebellum, which is the site of most gunshot injuries.

The Nature of the Symptoms produced by Cerebellar Lesions.

A study of the symptoms of destructive lesions and a determination of
their constancy and relative importance will form a sufficient basis for
the clinical diagnosis of diseases of the cerebellum, but in order to obtain
an insight into the normal functions and the physiological properties of
this organ it is necessary to analyse and attempt to resolve these numerous
functional disturbances into their simplest components.

This is unquestionably a difficult task ; in the past it has been the
subject of much discussion and controversy among physiologists, who can
■deal with simpler factors and possess means of measurements that are not
available to the clinician ; the clinician, however, has the advantage that
he can rely on the intelligent co-operation of his patients and consequently
employ more numerous and better adapted methods for observing thQ
effect of various lesions. Certain problems indeed, as the occurrence of
sensory disturbances, can be decided only by clinical observations.

The first point which demands attention is the nature of the symptoms
already described. Are they to be attributed to destructive or to irritative
lesions of the cerebellum ? Their constancy, their regularity, their
persistence for long periods, and especially their nature, suggest strongly
that they are directly due to destruction and that they are consequently
negative or defect phenomena. In the case of many of them, as the

24 The Symptoms of Acute Gerehellar Injuries

muscular atonia, this cannot be doubted, and indeed careful observation
makes it probable that irritative effects are minimal after gunshot injuries
of the cerebellum in man. Those forced movements and attitudes which
Luciani has tentatively termed "dynamic phenomena," that occur so
commonly after experimental injuries in animals, are very rarely seen in
man, or occur at least only as immediate symptoms. Vertigo, if it is to
be included among the true cerebellar symptoms, is more probably of
irritative origin ; its inconstancy, its variability, and the facts that it
occurs only early after the infliction of the injury and is rarer in gunshot
wounds than in cases of tumour or abscess, favour this view. It may
be consequently safely assumed that the functional disturbances with
which we have to deal are produced only by negative or destructive
lesions of the cerebellum.

It is worthy of note that, as von Monakow has pointed out, symptoms
referable to the effects of shock or diaschisis on other parts of the nervous
system are rarely obvious.

Atonia, or diminution of that slight constant tension which is charac-
teristic of healthy muscle, is such a constant and striking feature of all
early injuries, and persists for such long periods when the wounds are large,
that it is obviously a primary and direct symptom.

The state of the tendon-jerks has been generally taken by clinicians as
a measure of tone, and yet it is the rule that even in the toneless limb
of a cerebellar patient the knee-jerks and similar reflexes are not abolished,
and the excursion of the jerks may be even larger than on the normal side.
Physiologists too (Risien Russell, Andre-Thomas) have found the homo-
lateral reflexes exaggerated after unilateral experimental ablation. But
tone is dependent not only on the activity of the direct spinal reflex arc, the
integrity of which is essential for the presence of the knee-jerk, but on
other factors too, as on labyrinthine and cerebellar influences ; or rather
that state we call tone is influenced hy several factors and the presence
of the knee-jerk indicates only the activity of one, that is of the spinal
reflex arc. Consequently the presence of the knee-jerk is not an argument
against the existence of atonia in cerebellar disease.

But even when septic infection and the effects of increased cerebro-
spinal pressure can be excluded the knee-jerk and the other tendon reflexes
are in some cases depressed, or they may be even for a time absent, on
the side of an early and extensive lesion. As far as clinical observations
go this seems to be generally associated with an extreme atonicity of the
muscles, but their relation is probably not direct. The depression of the
reflexes may be due to transient shock or diaschisis as it is an early
hemiplegia ; or it is perhaps owing to the fact that the muscles are so
atonic that a tap on the tendon does not produce a sufficient increment of
tension in them to be an adequate stimulus. The common observation

Gordon Holmes 25

that a reflex response can be frequently elicited by only one of a series of
taps, or when the knee is in a certain position, and that it is then quite
brisk, favours the latter hypothesis.

Recent physiological investigations (Sherrington, Langelaan) have
shown that tone is a more complex condition than has been generally
realized by clinicians; it may indeed be a compound state, its separate
components being perhaps dependent on distinct elements of the muscle
fibres, and possibly on separate innervation.

If these views prove correct it will be the task of experimental
physiology to determine what component of tone is affected by cerebellar
injuries. The study of the knee-jerk by the graphic method shows that
the tonic contraction of the quadriceps, which prevents the free and
immediate fall of the extended leg under the influence of gravity, is absent
or diminished when the homolateral side of the cerebellum is injured ;
the jerk has then the character of that described by Sherrington when the
reflex excitabihty of postural contraction is low, or when what Langelaan
calls plastic tone, that is the slow yielding of the extensor muscles to a
continued stress, is absent or diminished.

Langelaan has indeed already suggested that decpebrate rigidity is
partly due to a spasm of the muscle sarcoplasm of sympathetic origin
owing to the prevailing influence of the cerebellum, but Horsley and
Clarke found that decerebrate rigidity persists after destruction of the
cerebellum, unless the paracerebellar nuclei too are injured, and Sherrington
also states that the cerebellum can be removed without the posture in this
condition being annulled.

It appears obvious however that the various symptoms of atonia
described above can be attributed to this loss or diminution of postural
contraction or plastic tone ; its absence abolishes the normal resistance
of the various segments of the limbs to passive movement, leaves the
muscles less elastic to sudden stretching, and makes them soft and flabby
to palpation.

Clinical experience, therefore, fully confirms the statements of Luciani
and other physiologists that atonia is a constant, important and striking
result of acute cerebellar destruction. It diminishes gradually in time,
and may, like all the other symptoms, disappear, at least if the lesion is
not very extensive. I have, however, at present no definite observations
on this point, nor will it be possible to obtain satisfactory conclusions until
we possess a reliable clinical method of measuring tone.

The remarkable fact that atonia as a symptom of cerebellar disease

has received little attention from clinicians is probably due to its gradual

decrease after the onset of acute lesions, and to its compensation pari

.passu with the progress of degenerative and atrophic diseases. Babinski,

for instance, states that even in particularly severe cerebellar affections

26 The Symptoms of Acute Cerebellar Injuries

he has found no atonia, and Andre-Thomas in 1911 wrote that he had
never observed muscular relaxation or hypotonia, in the sense which is
given to it by clinicians, in any patients he had examined.

The latter author, however, in 1914, elaborated in conjunction with
Durupt an hypothesis, foreshadowed by Kothmann, according to which focal
lesions of the cerebellar cortex produce a condition of anisosthenia, or
hyposthenia of certain muscles and hypersthenia of their antagonists.
Of this condition I could find no evidence either when only local circum-
scribed lesions existed, or as the symptoms of more extensive injuries
cleared up.

The next group of symptoms that claims our attention are those seen
in voluntary movement. Certain of them are most easily studied in simple
actions against resistance. It has been shown that when a man with a
cerebellar lesion attempts to grasp the observer's two hands simultaneously :
(1) the power exerted by the affected limb is defective ; (2) the initiation
and the execution of mUscular contractions and relaxations are slower
than on the normal side ; (3) the grasp is often intermittent and irregu-
larly maintained ; and (4) the affected limb tires more quickly than its
fellow. These symptoms can be equally well demonstrated in other actions.

Asthenia. — This term, which Luciani has applied to the diminished
functional energy of the affected limb, may be conveniently used to
describe their lack of normal power in movements that demand its
exertion. It differs so definitely from the paralysis and paresis produced
by disease of the motor system that it is advisable to designate it by a
distinct word.

That any degree of feebleness is ever produced by cerebellar lesions
has been denied by many, and others who have observed it have attri-
buted it to pressure on the motor tracts (Rothmann), to co-existing
cerebral foci, to atonia, or to ataxia (Mann). In the early stages of
every severe injury it is, however, easily determined that the homo-
lateral limbs are feebler than their fellows, and when their strength is
measured a very considerable reduction of power may he found in all
groups of muscles, though it is usually more obvious in the arm than in
the lower extremity. The greater effort necessary to deviate the eyes fully
towards the side of the lesion, and the frequent defect in the range of
their movement in this direction, is another manifestation of this asthenia.
It has been already emphasized that the asthenia is not due in any large
part to ataxia or awkwardness of the limb and a consequent misdirection
of its energy ; and though it is usually most definite when the limbs
are very hypotonic it cannot be attributed to loss of tone, as these two
symptoms bear no relation to one another. Asthenia must be conse-
quently regarded as another primary and immediate symptom of cerebellar
injury. It is probably pronounced only when the cerebellar nuclei are

Gordon Holmes 27

involved. The abnormal fatiguability of the affected limbs is associated
with, and may be regarded as a result of, this asthenia.

Slowness in movement has been noticed by both clinical and experi-
mental observers. It is certainly not willed or intentional as Andre-
Thomas states, nor can the delay be attributed to time lost in " taking
up skick " in the atonic muscles, since the latency of toneless muscle
is very short (Sherrington), and this explanation -would not account for
the closely associated delay in relaxation. And since it occurs in the
simplest actions, as in simple flexion of the fingers or elbow, it is
obviously not dependent on the inco-ordinate and inappropriate muscular
associations which disturb voluntary movements. Finally there is no
evidence that a contraction or state of increased tone of the antagonists
delays or impedes the shortening of the contracting muscles.

In order to understand its nature it is necessary to study simple
actions, and if possible by the aid of the graphic method. It is then
seen that it is due both to delay in starting the contraction and to slowness
in completing it. Further careful examination shows that there is usually
associated with it a similar delay in commencing and completing the
relaxation of the same muscles, which is occasionally even more pro-
nounced. This slowness may be due to retardation of the impulses that
excite voluntary muscular contractions ; or to the fact that certain nervous
mechanisms concerned in the production of voluntary movement react too
slowly to these cerebral impulses ; or it may be dependent on a state of
the muscles owing to which their contractions and relaxations are retarded.
As there is no evidence or probability that the cortical motor centres from
which these impulses come are in any way affected the first of the hypo-
theses may be excluded. And as there is not a corresponding delay
in the contractions and relaxations of muscles that are excited electrically
or reflexly there is not sufficient basis for the third possibility. It con-
sequently seems that the cerebellum exerts an influence on the nervous
mechanisms, most probably on the spinal, immediately concerned in the
execution of voluntary muscular contractions, by virtue of which these
react promptly to cerebral impressions.

The cerebellum might be therefore regarded as a motor reinforcing
organ, in the sense in which Luciani and others have used this term.
It seems, however, probable that it takes no direct part in the processes,
'whether initiated reflexly or voluntarily, that produce motor effects, and
that it does not augment these, but that it " sets " or " tunes," or regu-
lates the activity of certain motor mechanisms, most probably spinal, so
that the response to a volitional stimulus is immediate, effective and
proportional to the intensity of the cerebral impulse.

Closely associated with asthenia is the discontinuity and irregularity
in the maintenance of muscular contractions. This disturbance can be

28 The Symptoms of Acute Cerebellar Injuries

observed in almost all voluntary movements and in the contractions of
muscles concerned in maintaining posture (static tremor), but it is most
easily studied in actions that demand the exertion of power ; in these
the contractions reach their maximum slowly and intermittently, and while
in the normal limb a forcible contraction can be maintained regularly for
some time, the grasp or other action which the patient attempts wifeh the
affected limb is often discontinuous and irregular, and it is frequently inter-
rupted by sudden relaxations. The outstretched arm if unsupported often,
for instance, falls suddenly, and in walking the affected leg frequently gives
way under the patient without any apparent cause. The tremor that occurs
in maintaining an attitude and in voluntary movements is due to this
defect in the regularity and stability of the muscular contractions. Luciani
has described this condition as astasia, and has attributed it to the imper-
fect fusion and summation of the single twitch contractions. Patrizi has
indeed shown experimentally that cerebellar lesions lead to an incomplete
fusion of the elementary twitches in muscles.

Astasia is not, however, such a prominent symptom in most local lesions
of the cerebellum in man as it is in animals after experimental destruction,,
though it varies in degree in different cases. It does not seem to stand in
any close relation to the atonia and it is probably not in any way dependent
upon it ; it is, on the other hand, intimately associated with asthenia.
Consequently, in addition to that function by virtue of which it assures that
the motor response to a voluntary cerebral impulse shall be immediate
and proportional to the impulse, the cerebellum also exerts an influence on
the efficiency of this response by determining the complete fusion of the
elementary muscle twitches.

Clinical observations consequently confirm Luciani's conclusions that
atonia, asthenia and astasia, the triad of symptoms to which he attributes
all the functional disturbances, result from cerebellar lesions.

But there are other symptoms that cannot be explained by these factors
only. Among them is the rebound phenomenon which throws considerable
light on the nature of the motor disturbances. The excessive range of the
after-movement may be due to absence or to long delay of the voluntary
contraction of the antagonistic muscles ; the fact that the patient's hand
can be flung forcibly into his face shows indeed that prompt voluntary
arrest is not possible, but it must be ascribed mainly to failure of the
immediate reflex contraction of these antagonists when they are suddenly
stretched. The absence of contraction of the hamstrings when the knee-
jerk is elicited mider ceiitain conditions is a similar phenomenon ; the
muscles do not react normally to a sudden putting on stretch. It is true
that the same may be observed in other conditions associated with loss of
tone, as in peripheral nerve lesions and in tabes dorsalis, but the fact that
the tendon-jerks, which must be regarded as reflexes of the same nature,

Gordo7i Holmes - 29

are not as a rule lost and may be exaggerated in cases of cerebellar injury
shows that the atonia associated with this condition does not affect this
form of reflex function. Both the biceps and triceps reflexes are in fact
quite brisk in cases in which the rebound phenomenon can be demonstrated
in extension and flexion of the forearm. It may be consequently assumed
that the rebound phenomenon is not directly due to loss of muscle tone,
but to failure of the muscles to contract promptly and efficiently when they
are suddenly put on stretch. It is a manifestation of the loss of what
Kothmann has called the antagonist's reflex.

On analysing the complex condition often called cerebellar ataxia, we
meet with other facts that cannot be explained by atonia, asthenia and
astasia alone. The kinetic tremor is, it is true, chiefly a manifestation of
astasia, but the disturbances termed asynergia, decomposition of movement,
and deviation from the Ime of movement, must be considered more fully.

The term asynergia here implies a defect in that accurate functional
combination of the muscles which participate in a movement, that is the
agonists, antagonists, synergic and fixating muscles, on which the precision
and correct adaptation of the movement to its end depends. We have seen
that on closing the fingers the wrist is often hyper-extended, or it extends
too little or too late, and when the fingers are rapidly flexed and extended
the appropriate wrist movements do not occur simultaneously. Here the
co-operation of the agonists and their synergies is obviously disturbed.

Again, when the patient attempts to bring each finger in succession to
the tip of his thumb all or several of his fingers flex simultaneously, and
much the same may be seen when he handles a small object ; this is due
to the agonists and antagonists not working properly together as they
must to permit the flexion of an isolated finger. Similarly, in rapid
alternate movements one or other excursion is often abruptly arrested
owing to disturbance in the reciprocal relations of agonists and antagonists.

And as the patient attempts to pronate and supinate his forearm
quickly, various irregular and inappropriate movements occur at the
shoulder, elbow and even at the wrist, owing partly at least to
defective fixation at these joints.

Finally, when for example he flexes and extends his ankle alternately,
the knee and hip often flex and extend simultaneously, owing, not to
defective fixation but, as may be easily determined by palpation, to active
contractions of the thigh and pelvic muscles. Here the intervention of
muscles that should not be concerned in the action disturb its precision.

Other instances can be easily cited of all these forms of disturbance.

This affection of the normal harmony and correct co-operation in time
and degree of the various muscular contractions concerned in movements
and m the maintenance of posture is such an important factor in cere-
bellar symptoms that it claims careful attention. It is essentially an

30 The Symptoms of Acute Cerehellar Injuries

inco-ordination or ataxia (i.e., absence of discipline or arrangement) of the
active muscles, though these terms have become so vague and have given
rise to so much confusion that they must be reluctantly employed.
Parenthetically it may be pointed out that ataxia, when employed in its
literal sense, is more correctly applicable to these disturbances than to
that component of the irregularity of movement seen in tabes dorsalis,
which depends upon or is influenced by loss of the sense of position,
and which is consequently most pronounced when the movements of
the limbs are not controlled by vision.

A disturbance in the co-ordination of the muscles engaged in individual
movements must be therefore accepted as a symptom of cerebellar disease,
and its acceptation does not involve the " creation of an abstract and
fictitious entity, the principle of co-ordination." All actions are the
product of the activity of several and subcortical centres, and though it is
the cortex which initiates voluntary movement and probably selects and
integrates the adequate impulses for individual acts, the elaboration and
co-ordination of the numerous factors that are concerned in each must
depend largely on subcortical centres. We have learned from Sherrington's
work the elaborate integration of which even the isolated spinal cord is
capable in reflex acts. His experiments have demonstrated that it is on
the afferent impressions of the proprioceptive system that the control and
regulation of the spinal reflexes chiefly depend, and numerous experiments
and clinical observations have shown that this system exerts similar
functions in voluntary movements. Professor Sherrington has happily
described the cerebellum as " the head ganglion of the proprioceptive
system," and if this view, which conforms to the anatomical connexions of
this organ, is accepted it would be natural that one of its chief functions
should be the exertion of a regulating and co-ordinating influence in
more complex movements.

Babinski has applied the term asynergia particularly to the inability
to perform simultaneously the various movements that constitute an act,
and we have seen that this condition, which has been referred to here
as decomposition of movement, does occur, especially in recently wounded
patients. Andre-Thomas and Durupt attribute it partly to voluntary
dissociation and partly to dysmetria. That it is often voluntary there can
be no doubt ; one ataxic patient for instance when given a spoon and told
to place it in his mouth always brought his elbow down to his side and
held it firmly applied to it before moving his hand towards his face, in
order, as he explained, to control as well as possible the disorderliness of
his movements. But my observations convince me that it is not always
intentional, at least in its milder forms, and that it may be a result of
faulty association in time and degree of the various muscular contractions
that are concerned in the action.

Gordon Holmes 31

The symptoms described under the term chjametria are more difficult
to interpret. Luciani, who introduced this term, regarded it as a natural
consequence of atonia ; according to him the excessive elevation of the
leg is due to a too sudden relaxation of the extensors as the flexors con-
tract, and he therefore refused to accept it as a primary cerebellar
symptom as Schiff had previously considered it. Babinski, who has
pointed out its importance in clinical symptomatology and the fact that
the movements are generally excessive in range, admits he does not under-
stand its nature, though he suggests that it may be due to removal of an
inhibiting or braking function ("action frenatrice ") of the cerebellum.
Andre-Thomas regards dysmetria as the most important factor in the
disturbance of movement; he formerly assumed (1911) that the influence
of the cerebellum is manifested in moderating the voluntary impulse, and
not in causing the antagonistic muscles to intervene, but later he has
attributed it, as well as most of the other symptoms, to anisosthenia ; the
movement is excessive because the hypersthenic muscles contract too
vigorously, and because it is arrested too late or insufficiently owing to the
hyposthenic state of their antagonists. I have observed no facts that
support this explanation, nor is it intelligible to me how hypermetria
Would, on this hypothesis, result from extensive lesions or widespread
disease which must involve numerous pairs of his reciprocally functioning
" dynamogenic centres." Further, movements in opposite directions at
the one joint are generally both hypermetric; and, as Babinski has pointed
out, excessive movements are common in chronic cerebellar disease in
which there is little or no demonstrable atonia.

The main cause of hypermetria is the pathological slowness in com-
mencing and in completing the relaxation of the contracting muscles.
While delay and slowness in starting contractiotis may cause no
pronounced disturbance^ of voluntary movement, a delay in the arrest
of the contraction and a slowness in affecting relaxation must necessarily
prolong the movement or continue it too far, and consequently make its
range too great. In several of the latter cases of my series this explanation
was carefully tested and in all it was found that when there was a definite
tendency to hypermetria in any movement the muscles which eff"ected
it relaxed more slowly than their homologues in the normal limb.

It often seems, however, that the exaggerated movements are to some
extent due to the failure of their prompt arrest by the contraction of their
antagonists ; when, for instance, towards the completion of the action the
hmb moves with gravity it is often allowed to fall inertly on the object it
wishes to seize. The timely intervention of the antagonists is then
absent, as it is in the rebound phenomenon, but this cannot be attributed
to their hypotonia, as Andre-Thomas suggests, for the proper co-operation
of agonists and antagonists is an integral factor in voluntary movement,,
and depends on the co-ordination of the subcortical centres that effect it.

82 The Sy7npto77is of Acute Cerebellar hijuries

But the mismeasured movements are occasionally too small. This may
be due to intentional arrest — we have, in fact, seen that this often occurs —
or to an under-estimation of the effort necessary to move the slow and
asthenic limb; but it is chiefly a result of the defective co-ordination
of the various muscles concerned in the act, which necessarily disturb
its range as well as its direction.

The deviation from the correct line of movement, which is prominent
chiefly in early injuries, is a natural result of the functional disturbances
which have been already considered. The limb deviates, especially in the
early part of the movement, because the muscles that should be employed
in fixing certain of its joints and in maintaining its correct posture
contract inadequately or too late. Further, since the co-operation of
those concerned in it, whether they contract or relax, is no longer
accurate, the moving limb is not brought in the most direct line to its
object, even though the general direction of its movement is correct.

All these disturbances are well brought out by Babinski's tests for
adiadochokinesis. Kapid alternate movements are slowly, awkwardly, and
irregularly performed, owing to the slowness in the initiation of each, the
irregularity in their range and the disturbance in the normal co-ordination
of the muscles that should contract, those that should simultaneously relax,
and those that should assure the correct posture of the limb. The more
rapidly the movements are performed the greater is the need of accurate
co-ordination, since any irregularity or defect in one must also influence the
proper execution of the succeeding movements.

The same factors are responsible for the affection of speech ; its
slurred, indistinct, and scanning character results from the imperfect
harmony of the movements and attitudes necessary in normal phonation
and articulation, while the tendency to explosiveness may be regarded as
a manifestation of dysmetria. The unnatural efforts which the patient
puts into his attempts may be more easily interpreted as an attempt to
control voluntarily the disturbances of the complex and highly specialized
mechanism of speech, rather than to asthenia of the muscles of phonation
and articulation. The grimaces and unnecessary contractions of the facial
and neck muscles in a patient with a severe cerebellar injury often recall
those that occur on the inco-ordinate attempts of a mild stammerer to
speak.

We must consequently conclude that, in addition to its influence on
tone, and that by which it assures the regularity and maintenance of
muscular contractions and the immediate and effective response of sub-
cortical mechanisms to cerebral impulses, the cerebellum also exerts
a regulating and co-ordinating influence on the spinal centres that effect
voluntary movements and by this means assures their harmony,
precision and correct range. This does not mean that the cerebellum

Gordon Holmes 33

puts into play the muscles necessary for the accomplishment of compli-
cated movements. It is an organ which has evolved on the afferent
rather than on the motor side of the central nervous system. But it
receives and integrates proprioceptive impulses from all parts of the body,
and by virtue of these it keeps the motor mechanisms in such a state
of " tone " that it can react promptly and efficiently to reflex and voluntary
impulses, and assures the correct co-operation of the separate motor centres
that are concerned in individual acts.

After a recent injury of one side of the cerebellum the eyes when at^
rest tend to deviate towards the opposite side, and nystagmus occurs on
movement and especially on accurate fixation. This deviation of the eyes,
the greater effort necessary to move them towards the injured side, and the
frequent defect in the range of movement in this direction, must be
attributed to loss of an influence, probably of a reinforcing nature, which
each half of the cerebellum exerts on conjugate deviation towards the
same side. The effect of this loss is most evident in voluntary movement
but it may be seen, too, in the adjustment of the eyes when the head is
passively rotated, and when they move reflexly to a sudden visual or
auditory stimulus. As an analogous deviation is produced by unilateral
labyrinthine extirpation it is probable that this function of the cerebellum
depends largely on its labyrinthine afferents, but since in this condition
the deviation of the eyes is towards the injured labyrinth, and the
associated nystagmus differs in type, it is evident that the eye symptoms
of cerebellar disease are not due merely to interruption of labyrinthine
impressions ; it has, in fact, been found by experiment that the impulses
by which the labyrinth influences the ocular movements do not pass
through the cerebellum. (Wilson and Pike.)

Further, both the nystagmus and the paretic deviation produced by
cerebellar lesions, though not permanent, are more persistent than when
the vestibular apparatus only is destroyed. It is probable that it is to the
combination and integration in the cerebellum of labyrinthine and other
proprioceptive afferents, especially those from the ocular, and possibly
from the neck muscles too, that this influence on the movements and
position of the eyes is due.

The nystagmus is closely related to this symptom. When a patient
attempts to look towards the injured side the eyes are brought over
quickly, but they soon recede more slowly towards the middle line as
though the muscles were too weak to maintain the position, and are then
jerked back again in the desired direction. A series of these recessions
and corrections constitutes nystagmus. It consists of a slow phase towards
the position which the eyes assume when at rest, and a quick phase in
the direction towards which they should be moved voluntarily. The
range of both excursions increases the farther the object to be fixed is

34 The Symi->toms of Acute Cerebellar Injuries

from the middle line, that is, it is proportional to the effort necessary
to bring the eyes into, and keep them in the correct position. The
essential feature is the slow recession, which is only a manifestation of
the spontaneous deviation, while the quick phase can be regarded as an
attempt at correction. It has been shown by Wilson and Pike that in
labyrinthine nystagmus the quick jerks are of cerebral origin, and the
same is probably also true of cerebellar nystagmus. There can be no
doubt that this is always more marked when the patient makes a
Voluntary attempt to fix an object than when his eyes are at rest or
moved to order. It is interesting that nystagmus is more pronounced
and more persistent in man than in animals; this is probably related
to the greater development of the forebrain, and to the larger part that
this takes in the execution of ocular movements.

The nystagmus that occurs on central fixation is similar. The eyes
still tend to recede towards the healthy side, and their recessions are
corrected by similar sharp abrupt jerks. It is important in support of
the above explanation, that nystagmus on central fixation is pronounced
only when a tendency to spontaneous deviation exists.

On full deviation towards the unaffected side and on vertical move-
ments a similar nystagmus may also occur, the slow phase being towards
the primary central position, or more correctly towards that point in
space to the healthy side of it on which the eyes tend to deviate when
at rest. It consequently seems that each half of the cerebellum has an
influence, not only on conjugate movements of the eyes towards the same
side but also on vertical movements and on full deviation towards the
opposite side. This influence is probably closely allied to that by which
the normal labyrinth assures the adjustment of the eyes to change of the
position of the head in space, and is adjunct or reinforcing to the processes
which effect voluntary deviations and reflex ocular movements of other
origin. That this reinforcing action should be more pronounced in the
ocular movements than in those of the trunk and limbs is not surprising
when the greater extent to which the ordinary movements and adjust-
ments of the eyes are dependent on subcortical mechanisms, and especially
on labyrinthine impressions, is realized.

This type of nystagmus cannot be regarded as an ataxia of the
ocular muscles; it is usually a well co-ordinated phenomenon in which
the co-operation of the various muscles concerned in movement and
fixation is undisturbed, though it may be occasionally seen that the
adjustment of the visual axes to the object that should be fixed is
imperfect.

The mode in which lesions of the cerebellum influence the posture of
the head, trunk and limbs is more obscure. Those abnormal postures that
result from unilateral lesions are much less marked and less persistent ia

Gordon Holmes 35

man than in animals, and even in these physiologists have not yet reached
any definite or generally accepted hypothesis as to their nature.

The most striking and constant of the abnormal attitudes is that
assumed by the head and the tendency of the affected limbs to deviate
when unsupported and in movement (Barany's pointing test). The head
is as a rule inclined towards the injured side and rotated to the opposite, so
that the occiput approaches the homolateral shoulder. It is noteworthy
that this position also occurs after destruction of one labyrinth, and
Horsley has indeed suggested that it should be regarded as a labyrinthine
rather than a cerebellar attitude. It may be that it is through the cere-
bellum that the labyrinth exerts this posture influence.

The deviation of the limbs when unsupported and in movements
uncontrolled by vision is a more important problem, since Barany and
Andre-Thomas have laid much emphasis on it in discussing the normal
functions of the cerebellum. I have not been able to observe the aniso-
sthenia to which Thomas and Durupt attribute it, and to explain it by the
relative hypertonicity (that is, excessive tonic state) of certain groups of
muscles and hypotonia of their antagonists, is, unless this condition of
tone can be detected by other tests and in other movements, merely to
restate the question. Since analogous deviations are produced by laby-
rinthine lesions, Barany's conclusion that they are due to the interruption
of labyrinthine impulses in the cerebellum is plausible.

The tendency to fall and to deviate to the injured side in standing and
walking are analogous symptoms, which may be attributed to loss of motor
balance between the two sides of the body owing to the removal of an
influence which each half of the cerebellum elaborates mainly from laby-
rinthine impressions. The other disturbances of equilibrium and, of gait
are due to those abnormalities of movement seen in all actions of the
affected limbs, and which are more pronounced the more complicated and
delicate the action is, and the greater the number of muscles it employs.
My observations lend no support to the view held by many physiologists
and clinicians that the predominant function of the cerebellum is the
maintenance of equilibrium.

Functional Localization in the Cerebellum.

The experiences of this war will probably settle the question of localiza-
tion in the human cerebellum, or rather in its cortex.

It must be admitted that the results of physiological experiments are
strongly in favour of it. Sir David Terrier's electrical stimulations,
Bolk's anatomical researches, and the observations of numerous pkysi-
ologists as van Eynberk, Rothmann, Andre-Thomas and others, on the
symptoms produced by small circumscribed lesions, seem at first sight
to prove conclusively that a localization of function does exist in the cortex.

36 The Synvptoms of Acute Cerehellar Injuries

But when they are more carefully examined so much discrepancy is found,
even between the results of experiments made in the same animal class,
that they are less convincing.

Further, Horsley and Clarke's careful researches have shown that the
cerebellar cortex is inexcitable to electrical stimuli ; and many of the local
lesions from which the most definite conclusions have been drawn extended
to or involved ,the nuclei. And even a constant correlation between
structure and functional adaptation is an unsafe argument, though a
valuable guide, for the physiologist.

My own observations are of only negative' value. I have attempted to
determine the position of the injury in every case by careful observation
at the time of operations, by a study of radiographs which revealed pene-
trating fractures of the skull or the presence of foreign bodies in the
cerebellum, and by post-mortem examinations. For this purpose it was
necessary to learn the relation of various points on the surface to under-
lying parts of the cerebellum ; this was done by modelling plasticine to
represent the covering scalp and soft tissues, on to a dried anatomical skull
in which a cerebellum was placed. When the position of the entrance
wound and its direction were known, an approximate idea of the region
injured could be then obtained.

In many cases the primary wounds were large, and the softenings,
haemorrhages and septic processes that so frequently accompany such
injuries undoubtedly increased the extent of the destruction. In others,
however, only small local lesions probably existed ; in three men, for
instance, the missiles, a small shrapnel ball and fragments of shell casing
respectively, were merely embedded in the skull, but on removing them
small lacerations were found in the dura mater through which some
softened cerebellar tissue escaped, and in several other cases similar cir-
cumscribed lesions were produced by small depressed fractures.

On investigating the sites of the wounds it was found that the
majority involved the posterior-inferior surface of the cerebellum, most
were in fact referred to the lobus gracilis, but practically every region
except the anterior-superior margin was affected in one or more cases. In
two patients, for example, depressed fragments of bone were driven along
the under surface of the tentorium, so that the injury was almost limited
to the superior surface, and in several others this surface was wounded
by missiles which had entered through the occipital or parietal lobes and
had penetrated the tentorium. In a few cases missiles of higher velocity
had passed through different portions of the cerebellum. In some patients
the Ifesions were more or less mesial, in others they involved its lateral part.

Final conclusions on localization can be drawn only from cases con-
trolled by complete anatomical examinations. But, on the other hand,
if there is a focal localization of function in the cortex some definite
evidence of it should be obtained from such material as has been available

Gordon Holmes 37

to me for investigation. Of such localization I could, however, find no
certain evidence. When small superficial lesions existed, they produced
only slight and transient symptoms which were never limited to one
segment of a limb, or even to one limb. On the other hand, unilateral
lesions produced symptoms which were always limited to the same side,
and we can consequently assume that the functions of the cerebellum are
always limited to the same side of the body.

It is true that the muscles of the head, neck and trunk, including
those concerned in phonation and articulation, are more seriously
affected when the vermis is injured, and disturbances of their function
are usually more obvious in mesial than in lateral lesions of one lateral
lobe ; it is therefore probable that these activities, which require the co-
operation of homologous bilateral muscles, are represented in or near
the vermis.

A special interest has been given to the question of functional localiza-
tion in the human cerebellum by Barany's publications. According to his
views there exist centres for the direction of movement in the cortex, and
a further representation of muscles, according to the articulations they
move, within these centres. He has come to this conclusion after investi-
gating the deviations of the affected limbs when they are unsupported and
in movements which are not controlled by vision, and from the fact that
when local lesions exist the deviations in certain directions which are
normally produced by stimulation of the labyrinth no longer occur. I have
found however that a unilateral injury of any part of the cerebellum almost
invariably causes deviation, both spontaneous and in the pointing test, of
the homolateral arm outwards, while the vertical errors are frequently
inconstant. Eothmann and others have also drawn attention to the
frequency of outward deviation. Since in my cases many different regions
of the cerebellum were involved, these facts are difficult to assimilate with
Barany's hypothesis of distinct focal centres for movement in different
directions.

As the majority of my patients remained under observation for only
relatively short periods after the infliction of their wounds it was rarely
possible to test the rotation or caloric reactions. In three cases, however,
both were examined, and in these it was found that immediately after the
appropriate labyrinthine stimulation the homolateral arm, which had
previously deviated outwards, no longer showed any tendency, or less
tendency, to deviate in vertical movements ; in other words, the normal
reactions were not abolished, but instead of producing deviation inwards
they merely corrected the outward deviation which previously existed.

The same condition was found in two other men whose cases are not
included in this paper. One had been wounded in the head twenty
months previously and had .been operated upon. No information on the
nature of the injury or on the extent of the operation could be obtained,

38 The Syynptoins of Acute Cerebellar Injuries

but there was a trephine opening over the right half of the cerebellum.
He came under observation with unmistakable symptoms of disseminated
sclerosis and had probably a large plaque in the region of Deiters' nucleus.
There was a marked tendency to spontaneous deviation of his right arm
inwards and to progressive deviation in this direction in vertical movements,
which increased after rotation to the left and on irrigation of his left ear
with cold water, but disappeared on rotation to the right and on irrigation
of his right ear. The irrigation of his left ear with cold water in the case
of a second patient whose right half of the cerebellum had been extensively
injured eight years previously also only corrected the constant deviation of
his right arm outwards.

If these observations are confirmed Barany's conclusions cannot be
accepted that local cerebellar lesions abolish certain deviations of the limbs
which are normally produced by stimulation of the labyrinth, since these
can still be elicited, though the error in movement is masked by an actual
or by a latent tendency to deviation in the opposite direction, which is
due to the cerebellar wound.

But though my observations lend no support to the theory of focal
localization of function in the cerebellar cortex they cannot be accepted as
proof that such localization does not exist.

There can be, however, no doubt that the relative prominence of
different symptoms, as tremor, slowness and inco-ordination of movement,
as well as nystagmus, varies with the site of the lesion. I hope to deal
with the question in a later communication.

REFEBENCES.

Babinsky et ToDRNAY. XVIIth Internat. Congress of Med., London, 1913 (Section of Neuro-
pathology), p. 1.
DE Castex. Rev. iieuroL, 1912, xx, p. 145.
Franz. Amer. Jcnirn. Insan., 1908-1909, Ixv, p. 471.
Goldstein. Neurol. Ccntralbl., 1913, xxxii, p. 1082.
Odillain, Barre et Stbohl. Bull, et M(^>n. cle la Soc. mid. des Hup. de Paris, 1916, xxxii,

p. 841.
Horsley. West Loud. Med. Journ., 1909, p. 149.
HoRSLEY and Clarke. Brain, 1908, xxxi.
Langelaan. Brain, 1915, xxxviii, p. 233.

LoTMAR. Monatsschr.f. Psychiat. u. Neurol., 1908, xxiv, p. 217.
LuciANi. " Human Physiology," iii (English trans.), London, 1914.
Maas. Neurol. Centralbl., 1913, xxxii, p. 405.
Mann. Monatsschr. f. Psychiat. u. Neurol., 1902, xii, p. 280.
Sherrington. " The Integrative Action of the Nervous System,'' London, 1906.
Idem. Brain, 1915, xxxviii, p. 191.
Stewart and Holmes. Brain, 1904, xxvii, p. 522.
Thomas. " La Fonction cerebelleuse," Paris, 1911.
Idem. Rev. neurol., 1915, xxii, p. 111.
Idem. Ibid., 1915, xxii, p. 1256.

Thomas et Durupt. " Localisations cerebelleuses," Paris, 1914.
Wilson and Pike. Phil. Trans. Roy. Soc., London, 1912, Section B, cciii, p. 127.
Idem, idem. XVIIth Internat. Congress of Med., London, 1913 (Section of Otology), p. 563.
Idem, idem. Journ. Amer. Med. Assoc, 1915, Ixv, p. 2156. ■

OBSEKVATIONS ON 250 CASES OF GUNSHOT WOUNDS OF
THE PERIPHERAL NERyES.

By Major C. NOON.

Royal Army Medical Corps.
Officer in Charge of the Surgical Division of the Norfolk War Hospital.

Between June, 1915, and March, 1918, 3G4 cases of injuries of the
peripheral nerves have been admitted to the surgical division of the
Norfolk War Hospital ; 250 cases have come under my observation, and
of these 102 cases have required operative treatment. It is chiefly upon
these cases that this paper is based. An attempt has been made to follow
up the cases, and to show the result obtained by operation up to the
present time.

Clinical Featuees of Nerve Injuries.

In every case of a gunshot wound of an extremity, it is of vital
importance to examine the limb for evidence of injury to the peripheral
nerves. No examination of a fracture would be considered complete with-
out an X-ray. No examination of a gunshot v/ound of a limb is complete
without an examination of the nerves of the limb. It is of great import-
ance that a diagnosis of a wounded nerve should be made at the earliest
possible time, so that an attempt may be made to prevent the development
of a useless, deformed, and contracted limb. The injuries inflicted on
nerves by gunshot wounds are very variable, but by a careful consideration
of the signs and symptoms produced it is possible to recognize several
distinct types of lesions. The clinical progress in a large number of cases
may be said to fall into one of the four following syndromes : —

(1) The syndrome of complete division of a nerve trunk. The signs
and symptoms vary necessarily with the functions of the afl'ected nerve,
but taking as an example a mixed sensori-motor, such as the median or
musculo-spinal nerve, the following phenomena may be observed.

Motor Phenomena. — There is immediate and complete loss of voluntary
power in the muscles supplied by the divided nerve. The paralysed
muscles waste and undergo degenerative changes which result in wasting
and deformities known as paralytic contractions.

Se7isonj Phenomena. — There is loss of protopathic sensibility. Proto-
pathic nerves respond to painful skin impressions, e.g., the prick of a pin,
and the distinction between extreme degrees of temperature. Their area
of distribution is badly localized, and stimulation of them gives a widely
radiating tingling sensation.

There is loss of epicritic sensibility. Epicritic nerves respond to light
touches, and also distinguish small difference of temperature. Their area
of distributionis well defined.

40 Cases of Gunshot Wouiids of the Peripheral Nerves

Vaso-motor Phenomena. — It is stated that there is an initial rise in the
temperature of the limb after the division of a nerve, with some redness
and increased vascularity in the part. This is usually followed by a fall
in the temperature of the part. The limb becomes pale and cold. It is
often found that the temperature of the injured part varies ver}' much with
external influences — in cold weather, for instance, the injured part may
assume a cold bluish appearance.

Trophic Phenomena. — A considerable time often elapses between the
time of the injury and the appearance of well-marked trophic lesions.
Sometimes trophic lesions will develop even after an operation has been
done for the union of the divided nerve. There is a diminution in the
quantity of the subcutaneous fat, the skin becomes smooth, and may be
abnormally dry, the hair is harsh and dry. Often blisters develop as the
result of trivial injuries, and in some cases the tips of the finger may
disappear as the result of progressive ulceration. Degenerative changes
also occur in the bones and small joints of the hand.

(2) The Srjndrome of CompressioJi. — This is an important group and
contains a considerable number of cases. If the signs and symptoms in
these cases be carefully considered, it will be noticed that there has some-
times been some improvement, but after a time this ceases and there may
be a relapse. This relapse is almost always due to compression of the
nerve by fibrous tissue, or the development of callus. Early diagnosis in
these cases is very important, as they are the most favourable for operative
treatment. A definite syndrome has been observed in these cases by
Stopford. This syndrome consists of a dissociated type of sensory
disturbance. The area in which there is a loss of sensibility to pain (tested
by a pin-prick) is greater than that in which the loss to light touch occurs
(tested by camel-hair brush). This syndrome is the reverse of that
enumerated by Head, Eivers, and Sherren for injuries of the peripheral
nerves. It is said not to be present on examination of recent mjuries, but
only develops at a later date. In cases of compression the motor paralysis
is less marked than in cases when the nerve has been divided, and the
muscular wasting is also rapid and not so extensive. Trophic lesions do
not occur in cases of compression.

(3) Syndrome of Incomplete Lesion ivith Irritation. — When this
condition is present the patient often complains of neuralgia pains. On
examination the extremity shows a glossy shining, and mottled red skin
which is often tender to stimuli. The skin in such cases is usually drawn
tightly over the fingers, the subcutaneous tissue is small in amount.
There is generally profuse sweating over the area of the nerve affected.
The sweat is strong smelling and markedly acid in reaction. Sweating is
usually not excessive, unless there is an irritative incomplete lesion.

(4) The Syndrome of Interruption, folloioed by Bestoration of Function.
— The cases following this course are probably examples of physiological
division. The missile having passed close to the nerve and temporarily

C. Noon 41

paralysed it, there is loss of sensation and of motor power, but there is
usually little or no muscular wasting. In a few weeks there is usually
evidence of returning sensation, and this is followed by the restoration of
tone and voluntary contraction in the paralysed muscles. These cases
usually recover completely in about three months.

Macroscopic Pathological Lesions of Peripheral Nerves, due to
Injury, with Special Reference to the Symptoms caused and
THE Treatment Necessary.

(A) Lesions of Nerves which give rise to Interruption of Functioyi ivith
Subsequent Becovery. — The pathological lesion in these cases is usually one
of concussion of the nerve. The missile has passed through the limb near
the situation of the nerve, without causing any macroscopic lesion. The
nerve has been merely concussed, or perhaps temporarily stretched. With
careful treatment these cases usually recover completely. In other cases
the missile may have caused some perineural haemorrhage. This com-
presses the nerve for a time, but on its absorption recovery takes place.
Operation in these cases is not required, recovery takes place in from two
to six months.

(B) Lesions of Nerves which give rise to Interruption of Function with
Incomplete Becovery. — The following pathological conditions often give
rise to incomplete recovery when not subjected to operation : —

(1) Concussion of the nerve with perineural suppuration which gives
rise to the formation of fibrous tissue.

(2) Partial neuromata which probably result from endoneural
haemorrhage.

(3) Laceration of the nerve sheath with adhesions to the surrounding
structure.

(1) Concussion of the nerve wath suppuration in the surrounding tissue
often gives rise to incomplete recovery, and this is extremely likely to
happen when insufficient drainage of the wound has been estabhshed.
Excessive formation of fibrous tissue takes place, and the nerve is partially
compressed by its development.

(2) The development of partial neuromata is a condition which probably
results from endoneural haemorrhage. The condition is recognized by
feeling a hard fibrous nodule, situated in a nerve which has beeii subjected
to injury. Recovery in these cases may be incomplete, but the prognosis
is good in those cases where there is only a partial loss of function. No
attempt should be made to excise these swellings, when only a part of
the nerve is affected, but the nerve should be placed in a bed of healthy
tissue.

(3) Laceration of the nerve sheath with adhesions to the surrounding
tissue. This condition is often associated with the signs and symptoms
of an incomplete lesion, with evidence of nerve irritation. The condition

42 Cases of Gunshot Wounds of the Peripheral Nerves

results from the nerve sheath having been torn by the injury, and inflam-
mation following the injury gives rise to adhesions which bind the nerve
down to the surrounding structures. An operation should be performed,
and the nerve freed from adhesions, and placed in a bed of healthy tissue.
(C) Lesions lohich Destroy Nerve Function : —

(1) Complete division.

(2) Compression.

(3) The development of a complete neuroma without resolution, that
is the development of fibrous tissue in the nerve prevents regeneration of
the nerve taking place.

(1) Complete Division. — In many cases of injury the nerve is completely
divided. The gap between the ends of the divided nerve varies much
according to the severity of the injury, and the amount of tissue damaged.
The cut ends of the nerve probably retract, and the gap is filled by a firm
homogeneous mass of scar tissue. The amount of scar tissue depends upon
the amount of suppuration. The greater the amount of suppuration, the
greater the amount of scar tissue. The development of scar tissue as the
result of suppuration, probably in all cases, forms a barrier, which prevents
the nerve ends uniting without surgical aid. If the wound is aseptic, the
ends of the divided nerve become united, and the conducting paths are
re-established by a regeneration of nerve tissue (Thomson and Miles's
"Manual of Surgery," vol. i.). This is not likely to happen, because when
a nerve is divided its ends usually retract, even when the wound remains
aseptic. But that it is possible is suggested by the following case : —

Case 1. — Injury to the left wrist, symptoms and signs of division of the
ulnar nerve. Operation refused. Spontaneous recovery.

Private F. McN. was admitted to the Norfolk War Hospital on
November 1, 1916. The patient stated that two months previously,
September 1, 1916, he cut his wrist by falling on some barbed wire; the
cut was a deep one, and he lost the sensation of the fourth finger, and
the ulnar side of the third finger.

Condition on admission to the Norfolk War Hospital, ISfovember, 1916 :
Examination of the left upper extremity, there was a healed wound at the
upper border of the anterior annular ligament over the situation of the
ulnar nerve. There was absolute loss of sensation over the area supplied
by the ulnar nerve in the left hand. The muscles -supplied by the ulnar
nerve showed obvious signs of wasting. There was loss of power in the
hand, and on electrical examination the muscles supplied by the ulnar nerve
showed the reaction of degeneration. The diagnosis of division of the
ulnar nerve was made, and operation advised. The patient refused opera-
tion. He was, therefore, treated with massage and electricity. The hand
continued to waste, and showed the typical appearance of division of the
ulnar nerve. At the end of four months, January, 1917, there was some
improvement, and on examination of the healed wound a well-marked
thickening could be felt in the course of the ulnar nerve ; three weeks later

C. Noon 43

and twenty weeks from the date of the injury the patient stated that he
thought he had some return of sensation in the hand. The condition of
the hand was certainly improving.

At the proximal end of a divided nerve a terminal neuroma will
develop. This bulbous end is firm, hard, and paler in colour than the
normal nerve. It is composed of partly fibrous and partly nerve tissue.
The development of a terminal neuroma is usually good evidence that the
nerve has been divided. Its size and development appear to be dependent
upon the condition of the surrounding tissues. Where there is much hard
and dense fibrous tissue surrounding the ends of the divided nerve, the
neuroma will be small and ill developed ; when the tissues are lax and
free, and where little fibrous tissue is present, it is probable that the
terminal neuroma will be large and well developed. The upper extremity
of the distal end is often shrunken, flattened, spread out, and difficult to
define. The whole peripheral part of the divided nerve may be thin and
wasted.

An operation is urgently needed in the case of a divided nerve. The
ends should be brought together and united as soon as possible.

Closely allied to the terminal neuroma is a condition which may be
described for convenience as a complete neuroma. This condition is
occasionally met with as a result of a severe injury to a nerve. On
careful observation of the nerve it is found that there is no break in its
continuity, and that its course is interrupted by a hard spindle-like
thickening. In other words, there is no firm homogeneous mass of scar
tissue, such as is found separating the ends of a divided nerve, but that
the nerve is continuous, except for the spindle-shaped swelling.

These cases require the most careful consideration in their treatment.
If the complete neuroma is associated with loss of sensation which has
been present for more than eight months, with progressive muscular
wasting and contraction of the muscles, then the best treatment is to
excise the swelling and bring the ends of the nerve into apposition. If,
on the other hand, the signs and symptoms do not seem to be progressive,
the muscular wasting is only slight and not progressive, and there are no
contractions, then it is best to be content to place the injured nerve in a
bed of healthy tissue, or to surround the seat of the lesion by a flap of fat.

In a paper on gunshot wound of peripheral nerves, Stockey writes thus :
"The temptation to excise all hardened .tissue about the nerve may lead
one into greater difficulties and prolong convalescence. We know that
nerve fibres will grow through considerable tissue resistance. If then, at
operation this be borne in mind, and in place of free excision in suitable
cases the nerve may be freed and wrapped in with a flap of fat or other
suitable tissue, recovery is more rapid and more complete."

To sum up, partial neuromata require protection. Complete neuromata
with progressive signs and symptoms require excision.

(2) Compression. — The chief causes giving rise to compression of nerve

44 Cases of Gunshot Wounds of the Peripheral Nerves

are severe injury with marked suppuration in the course of the nerve.
Compression is most likely to result in cases where there has been excessive
suppuration with insufficient drainage. When a nerve lies in close relation
to bone (for instance, the musculo-spiral in close relation to the humerus),
the formation of callus, with the subsequent implication of the nerve, is a
common cause of compression. These cases should be operated upon at
the earliest possible moment. These are the most favourable cases, the
prognosis being always good. The nerve at the site of compression will
look a little thinner than the rest of the nerve. In appearance it will look
a little whiter than the non-compressed part of the nerve, and on palpation
it will feel somewhat dense and firm. Eecovery in these cases is rapid
»fter the compression has been relieved, and the damaged part of the
nerve has been placed in a fresh bed or some soft tissue wrapped around it.

Time of Operation, Indication and Contra-indication for

Operation.

Suture of nerves may be primary or secondary. Much has been written
about primary and secondary suture for war wounds, which has been made
possible by the aid of the Carrel-Dakin treatment, and by the use of bipp.
Nothing or very little has been written about primary suture of nerves.
In this series of cases there have been only two cases of primary suture.
In one of these cases it was found necessary to again operate and perform
secondary suture.

Cases.

Gunshot wound of the left forearm, resulting in laceration of the
muscles and division of the ulnar nerve. Excision and repair of the wound,
primary suture of ulnar nerve (March 9, 1917). Operation followed by
marked suppuration and wound broke down. Secondary suture of ulnar
nerve, August 30, 1917.

E. E. received a severe flesh wound of the left arm on March 9, 1917.
An operation was done on the same day at a casualty clearing station. The
wound was excised, repaired, and the ulnar nerve sutured. The wound
broke down and suppuration was present for a considerable time.
Eventually the wound healed. The patient was admitted to the Norfolk
War Hospital on August 2, 1917, five months after being wounded. His
condition on admission was as follows : —

Examination of the left upper extremity ; there was loss of sensation
over the area of the distribution of the ulnar nerve in the hand, the muscles
supplied by the ulnar nerve also showed evidence of wasting. They do not
react to electrical stimulation, the hand was weak, there were no broken
lesions. The diagnosis of division of the ulnar nerve was made, and
although primary suture had been done, it was considered this had been a
failure, owing to the marked suppuration which followed the operation.
On August 30, 1917, an operation was done, the ulnar nerve was explored,.

C. Noon 45

and it was found united by about }, inch of dense scar tissue. This was
excised and the ends brought easily together without tension. There was
no evidence of any nerve fibres passing through the piece of tissue
removed. Since the operation progress' has been satisfactory. There was
little doubt that the primary suture made the operation of secondary
suture a much easier operation in this case.

Case 3.— Gunshot wound of the jight upper arm. Severe flesh. Drop
wrist. Operation. Recovery.

P. P. was admitted to the Norfolk War Hospital on August 7, 1915.
He had been wounded August 2. On examination there was a severe flesh
wound of the right upper arm. There was marked septic infection of the
wound. No injury of the bone was detected. There was wrist drop. An
operation was performed on August 8, the wound was laid freely open, and
the musculo-spiral nerve could be seen lying in the floor of the wound. It
had been partially torn. One suture was put into the sheath of the nerve
in order to draw the torn part of one nerve together. The patient
recovered the power of his wrist after eight months, but there was still
partial loss of power in the extensors of the second and third fingers.

On general prmciples it would seem useless to attempt primary suture
of a divided nerve, but primary suture, when the nerve can be seen lying
in a wound, with the hope of making any secondary suture at the proper
time a much easier operation, is most desirable whenever possible. The
results of secondary suture might be much more successful, although more
difficult to perform, if a primary suture has been done in the first place.
Secondary suture is accompanied with much more difficulty than primary
suture, owing to the greater retraction of the nerve ends, their bulbous or
filiform extremities being buried in scar tissue, or matted to the surround-
ing structures. These difficulties increase with time, so that provided
there be no contra-indications, the operation should be done at the earliest
possible moment. In the case of a completely divided nerve the recovery
of the nerve cannot start until the operation has been performed. In cases
of nerves being slowly strangulated by fibrous tissue or callus, the com-
pression may cause irreparable damage both to the nerve itself and to the
tissue it supplies. The earlier the operation the better the result in these
cases. Early operation is indicated in cases of (1) complete division,
(2) cases of compression, (3) cases of incomplete division where progress
is arrested, (4) cases of nerve irritation, (.5) cases of pain.

It has been said that a diagnosis cannot be made between anatomical and
physiological division in cases of nerve injury. In many cases this is true,
but from" observations on this series of cases it would appear that if a nerve-
lesion has not shown any signs of recovery within three or four months
from the time of the injury, some macroscopic pathological lesion will be
found on exploration of the nerve. This rule has only failed twice in this

series of cases.

When there has been no bony injury it is advisable that the wound

46 Cases of Gunsliot Wounds of the Peripheral Nerves

shall have been absolutely healed for at least one month before any
operation is performed. When there has been a septic bony injury it is
often advisable to wait three months after the wound has healed before
operating on the nerve. Septic infection means failure in these operations.
Most surgeons are in favour of early secondary suture of divided nerves for
the following reasons : The earlier the operation is done after the wound
is soundly healed the better are the anatomical relations maintained.
The amount of scar tissue is smaller in amount, and softer in texture, so
that it is more easily removed. If the nerve is not divided and only
imbedded in scar tissue, valuable tissue has been saved by the operation^
and perhaps irreparable damage prevented. The longer the operation is
delayed the firmer are muscular contractions, and the greater the atrophy
and degeneration of muscles, and the more likely are trophic lesions to
occur in the skin, muscles, bones and joints.

There are two contra-indications to operation, namely : —

(1) The wound is not yet healed.

(2) There are progressive signs of recovery in the function of the nerve.
Some neurologists hold that if an early operation is advised, a positive

diagnosis cannot be made, the nerve may yet recover. There is very little
to be said in favour of waiting for a patient to get worse in order to make
a positive and complete diagnosis. No surgeon waits for a malignant
growth to produce secondary deposits in lymphatic glands, why wait for
a divided nerve to produce degenerative changes in muscles and trophic
lesions? If there are sufficient signs and symptoms to suggest that the
nerve has suffered some macroscopic pathological lesion which is amenable
to surgery, an operation should be performed.

Pre-operative and Post-operative Treatment.

The operative treatment in these cases should be looked upon merely
as an incident in the treatment of the case. The most skilfullv performed
operation on an injured nerve is doomed to failure, and can accomplish
little if the pre-operative and post-operative treatment is insufficient or
neglected. The treatment in these cases should extend over a period of
many months. The results can only be good when treatment is com-
menced early and is conducted with great perseverance both on the part
of the patient and on the part of those who are responsible for his treat-
ment. It is often difficult or impossible in these cases to prevent such
complications and trophic lesions making their appearance, but if no
attempt be made to prevent and overcome these conditions irreparable
damage will supervene, damage which no amount of surgery can be
expected to correct. It is most important to try and make the patient
realize the importance of treatment, and to make him understand how
much he can do for himself to promote his recovery.

The treatment can be considered under the following headings : —

C. Noo7i 47

(1) Postural treatment.

(2) Electro-therapeutic treatment, including electric treatment, maSsage
and exercise.

Much has been written with regard to the positions which should be
maintained after a patient has suffered a lesion of a peripheral nerve, but
it must not be considered that everything has been done when the patient's
hand or leg has been fixed in the orthodox position by some splint. It
often happens that- these cases are complicated by some injury to the
bones of the limb. A splint is applied, fixing the whole limb. Of the
many inventions for the treatment of fractures, and especially those com-
plicated by nerve lesion, all are bad which hinder the easy movement of
the phalanges of the thumb and fingers. If the hand or the foot are left
fixed in any one position for long periods, and passive movements are not
frequently performed, disaster is certain to follow. It is quite as
important to remove a splint often as it is to apply it at all. The nutrition
of the muscles must be preserved as much as possible by massage and
electrical treatment. Vasomotor lesions are of common occurrence in
these cases, and it is often noticed that the limb affected is cold and
clammy. It is most important to keep these limbs warm, especially is
warmth important when electrical stimulation is being used as a method
of treatment. It is futile to apply electrical stimulation to cold and blue
extremities. The limb should previously be wrapped in warm cotton
wool, or immersed in hot water for a few minutes.

Joints must be prevented from getting stiff by passive movements,
which should have been begun as early as possible. Cases of stiff joints
will often be much benefited by hot-air baths. *

The condition of the skin itself must not be neglected, but must be
suitably protected from any injury. In short, every tissue enervated by
the injured nerve must have due consideration and treatnient. Treatment
should be regular and continuous. If operative treatment becomes neces-
sary massage should be again started as soon as possible, and in the upper
extremity every attempt should be made to prevent stiffness and contraction
of the hand and fingers occurring.

A position of relaxation should be maintained in all nerve injuries.

In median nerve injuries, the muscles supplied by the nerve are relaxed
when the fingers and hand are flexed, and the thumb abducted and flexed,
the arm being slightly rotated. Good results in this hospital have been
obtained in cases of simple uncomplicated lesions of the median nerve
without the application of splints.

In ulnar nerve injuries, the muscles supplied by the nerve are relaxed,
when the fingers are spread apart ; the first phalanges flexed, the second
and third extended and the thumb abducted. Every attempt has been
made to prevent contraction, and to maintain a position of relaxation in
lesions of the ulnar nerve, by means of splints and appliances, but more
success has been obtained by massage and passive movements, than has
been obtained by methods of fixation.

48 Cases of Gunshot Wounds of the Peripheral Nerves

In lesions of the musculo-spiral nerve, by means of a Jones's " cock-up "
splint, or some modification of it, the hand is hyperextended, the thumb
abducted, and the arm put in a position of supination, so relieving; the
extensor muscles of all strain. Operations on the musculo-spiral nerve
are doomed to failure if the paralysed muscles are allowed to become over-
stretched and lengthened by allowing the wrist to be in the flexed position
of "drop" wrist. If the wrist is kept in good position injuries of the
musculo-spiral nerve are among the most favourable for treatment.

It is useful before leaving the question of massage, electrical and
postural treatment, to answer the question : What can these methods of
treatment do for a patient who has suffered a nerve lesion, and how long
should such treatment be continued ? Massage, electrical and postural
treatment can prevent joints becoming stiff. It can prevent muscular
contraction to some degree, and it can maintain the tone of the muscles ; in
other words, it can enable the parts to be kept in the most favourable
condition for the resumption of their functions.

It can do little m late and neglected cases. One often sees hopelessly
contracted limbs with paralytic deformities, and with muscles the seat of
degenerated changes, sent to the massage and electrical department as a
last resource. These cases should have been sent to this department for
the prevention of these calamities, not for their relief, for the best massage
and electrical treatment is often almost a waste of time in these cases.
It is difficult to lay down any definite rules and say how long treatment
should be continued. Most cases show some improvement within six
months. Massage and electrical treatment should be continued for at
least six months after the operation on a nerve has been performed.
It is unlikely that treatment for more than a year will give rise to much
improvement.

Operation. — The operative procedure may be considered under the
following headings : —

(1) The skin incision.

(2) The isolation of the nerve trunk above and below the site of the
lesion.

(3) The freeing of the nerve at the actual site of the lesion.

(4) Passing the sutures, and the exact co-aptation of the ends of the
divided nerve.

(5) The formation of a sheath at the site of the lesion.

(6) Suture of the deep fascia and closure of the wound.

An operation having been decided upon, it should be performed under
general anaesthetic. The whole arm or leg to be operated upon should
have been previously prepared with the utmost care, any lesion of the skin
being an absolute contra-indication to the operation. It is a great
advantage to have a third assistant, whose only duty it is to control the
position of the arm or leg, and hold it in any desired position. This is
especially advantageous when operating upon such nerves as the musculo-

C. Noon 49

spiral. The operation is best performed without the application of an
Esniarch bandage. Any hasmorrhage which may occur is easily controlled
by the application of forceps, and the wound, when closed, is left dry,
there being much less risk of the development of any ha?matoma, a very
undesirable complication. The skin incision should be of ample length;
for instance, in operating on the ulnar nerve in the forearm, it is best to
make an incision from just below the elbow to just above the wrist ; the
skin having been divided its edges are protected by thin rubber sheeting or
gauze attached by means of clips. If possible, the skin mcision should be
planned so that it avoids the old scar, or the scar should be excised.
Excision or freeing the scar should always be practised wherever possible ;
the deep fascia is next divided, and any bleeding points controlled.

The nerve trunk is sought above and below the point of severance,
and it is traced downwards and upwards to the lesion. In doing this the
tissue surrounding the nerve should be dissected away from the nerve,
and the nerve itself should be handled as little as possible. On exposure
of the injured part of the nerve a bridge of fibrous tissue is usually found
joining the ends together ; it is best to dissect this quite free before
attempting to determine whether the nerve has been divided or not, so
that when the nerve has been completely freed its continuity has not
been divided during the operation. The fibrous tissue is then dissected
off the nerve, and a decision arrived at as to the pathological condition
present. When the conclusion is arrived at that the nerve has suffered
anatomical division, and its ends are only joined by a fibrous band, one
very fine silk suture is passed vertically through healthy parts of the upper
and lower ends of the nerve to be joined. This suture is a great aid in
maintaining the exact co-aptation of the nerve when suturing it after
removal of the intermediate fibrous tissue. Different bundles of the nerve
have different functions, so it is most important to bring the correspondincf
bundles together in the suturing. The nerve at the site of the suture
should be handled as little as possible. After the primary suture has been
passed, the supposed fibrous band is divided, and sections are cut from its
distal and proximal ends until nerve fibres are seen. The primary suture
is then tied, bringing the ends of the nerve into exact apposition; a series of
sutures unite the nerve sheath. It is most important to avoid tension.

I use the finest silk and the finest needles for suturing the ends of
divided nerves. Catgut is the material usually recommended. It appears
to me that the exactness and security of the junction is more important
than the suture material used to perform and make it. The necessity of
the formation of a sheath at the site of junction has next to be considered.
The nerve, after suture, should be placed in a bed of healthy tissue ; if this
can be done, it will not be necessary to surround it with any foreign
tissue.

Much has been written with regard to the surrounding of sutured
nerves with some material supposed to have protective virtues — a piece of
4

50 Cases of Gunshot Wounds of the Peripheral Nerves

fat, a piece of vein, cargile membrane, a piece of peritoneum from a hernial
sac, have all been recommended. A piece of fat of moderate thickness
cut from the patient's own thigh, and loosely sutured round the nerve so
as to protect the site of suture, makes an ideal covering and bed when
much scar tissue is present. If the operation is done aseptically the
procedure has everything to recommend it. It is advised by many
surgeons, and condemned by others, but the researches of Bittrolp appear
to prove that it is a sound and scientific procedure. It is doubtful if the
aseptic introduction of a piece of the patient's own fat can ever be harmful,
it is almost certain that it is often of great service. On completion of the
suture any bleeding points are carefully tied with catgut, and the wound
thoroughly irrigated with warm saline solution. The deep fascia is
carefully sutured with catgut and the wound closed without drainage.
The arm or leg is then carefully bandaged. The Hmb should be placed in
the best position to relieve the nerves from tension, and it should be fixed
in such a position by splints and bandages. Massage for the hand should
be started two or three days after the operation.

Complications. — The chief complications met with in this series of
cases have been : —

(1) Those due to septic infection of the wounds, extensive destruction
of the soft parts and severe injuries to the bones.

(2) Extensive destruction to the nerve, resulting in a gap in its
continuity, making end-to-end suture impossible.

(3) Drainage and rest for the inflamed parts have been relied on chiefly
to overcome the septic complications. With thorough drainage the
wounds have usually healed well, and given rise to little trouble. In a
certain number of cases of severe infection, associated with marked
swelling and oedema of the limb, it has occasionally happened that owing
to the pain it has been impossible to prevent some stiffness of- the fingers,
due probably to the inflammation spreading to the tendon sheath. In
such cases, after all the signs of inflammation have disappeared it will be
found that much benefit will be derived from gentle but firm movements
of the parts under an anaesthetic. The following case illustrates how
much good can occasionally be done by gentle movements under an
anaesthetic.

Case 4. — Gunshot wound of the right arm. Compound fracture of the
radius. Division of the ulnar nerve. Operation. Secondary suture of the
ulnar nerve, followed by stiffness of the fingers. Ansesthetic — movement of
fingers. Improvement.

J. G. was admitted to the Norfolk War Hospital on May 8, 1917. On
examination of the right upper extremity he was found to be suffering
from a compound fracture of the right radius, and an injury to the ulnar
nerve. On June 19, 1917, an operation was done, the ulnar nerve explored,
and found to have been divided. The divided ends were dissected from scar
tissue, the ends refreshed and united. The operation was not followed

C. Noon 51

by any marked improvement. In January, 1918, in spite of daily massa^'e
and electrical treatment, the fingers of the right hand had become stiff and
almost motionless ; any attempt to move them apparently caused great
pain. In February, 1918, an anesthetic was given, and the fingers gently
but forcibly moved. This was followed by marked improvement in the
movemeq^p of the band and fingers, and on leaving the hospital in March,
1918, the patient possessed a moderately useful hand.

In cases associated with compound fractures, very careful treatment is
necessary if necrosis with the development of a persistent sinus is to be
avoided, which may delay the suture of the nerve for many months.
These cases should be thoroughly drained at the earliest possible date,
and all loose pieces of bone which have not firm attachment to periosteum
removed. A healed wound must be obtained at the earliest possible time
in cases of compound fracture complicated by nerve lesions. Carrel-
Dakin treatment or continuous irrigation should be used as a method of
treatment when necessary.

(2) Extensive destruction of the nerve, resulting in a gap in its
continuity, making end-to-end suture- impossible.

End-to-end suture is the operation of choice. It should be done when-
ever possible. It will usually be found possible to perform end-to-end
suture after considerable pieces of nerve have been destroyed, if sufficient
attention -be paid to the following points: (1) The incision should be of
ample length, so that the nerve may be separated from the surrounding
structure, both above and below the lesion ; (2) in lesions of the ulnar
nerve, it can be displaced in front of the internal condyle of the humerus ;
(3) during and after the operation the position of the limb should be
put in that of maximum relaxation so that all tension is taken off the
nerve.

When it has been found impossible to perform end-to-end suture, a
variety of procedures have been attempted and advised, but it would
appear that up to the present time authorities have not been able to
determine the values of these operations, but from various writings it
would seem that their value is not great, and that for a few successes
there are many failures. Some of the procedures would, on general
principles, seem quite useless. The operation for uniting the ends of
nerves by cutting flaps has been condemned as useless, but that tins
method is sometimes followed by success is illustrated by the following
case : —

Case 5. — Gunshot wound of left forearm. Compound fracture of left
radius. Injury to the ulnar nerve, June, 1915. Operation August, 191.5.
Exploration of the ulnar nerve and suture by means of turned-down flap
from the upper end of the nerve to bridge a gap between the divided end.
Recovery.

Lance-Cpl. B. B. was admitted to the Norfolk War Hospital in June,
1915. On examination of the left upper extremity he was found to be

52 Cases of Gunshot Wounds of ilt Peripheral Nerves

suffering from a compound fracture of the left radius, together with an
injury to the ulnar nerve.

The wound healed well, but there was no improvement in the condition
of the parts supplied by the ulnar nerve. On August 30, 1915, an operation
was performed. The ulnar nerve was exposed in the forearm. It was
found to have been completely divided, and a large segment of ^le nerve
had been completely destroyed. When the divided ends had been dis-
sected free they could not be brought together. A flap was turned down
from the upper end of the nerve in order to bridge the gap ; union was then
made w^ith very fine silk. Slow improvement followed the operation.
The patient had been seen on several occasions since the operation. He
was examined in February, 1918, two and a half years after the operation.
There was some return of sensation in the area of distribution of the ulnar
nerve. There were slight contractions of the third and fourth fingers,
but the hand was an extremely good one. He was still in the Army,
and expected to be passed fit for general service at the next Medical
Board.

Under certain circumstances nerve suture may be replaced by tendon
transplantation, namely : (1) When nerve suture is impossible ; (2) when
the functional result attained by nerve suture is unsatisfactory. The most
favourable cases in which to prepare tendon transplantation are those of
injury to the musculo-spiral and posterior interosseous nerves. The trans-
plantation of the tendon of the flexor carpi radialis through and into the
tendons of the extensor longus pollicis, the extensor brevis pollicis, and the
extensors of the fingers is an operation followed by such good results that
it should always be done in cases when it is considered likely that the
musculo-spiral nerve will not recover. " Complete restoration of function
may be expected in four weeks, an enormous saving of time compared
with the year which must elapse before recovery after nerve suture." —
(Murphy).

Prognosis and Besidts. — The prognosis depends upon the variety and
severity of the injury and the complications present. Cases of physiological
division usually do well, and often recover completely in from three to
six months. Cases of compression require prolonged and skilful treatment
if they are to do well, recovery is often incomplete, but good results are
oftan obtained, and the disability usually is not great. The prognosis in
cases of complete division is always grave, especially if complications are
present. Great patience is required in the treatment of these cases. It is
doubtful if complete and perfect recovery ever results from a divided nerve,
but that much can be done to produce good functional results is undoubted.
The time taken for recovery is often long and progress slow, but some
cases continue to improve for two or three years after the operation of
suture of the nerve has been skilfully performed. It is difficult to follow
up cases for a long period of time. A few cases in this series have been
observed for as long as two and a half years, the results have been grati-

C. Noon 53

fying in these cases which have been observed for a long period. The
average duration of observation after the operation has been over eight
months. This is too short a time to obtain the final results, but it is long
enough to form some estimate as to what they are likely to be.

In attempting to sum up the results a careful record has been taken of
the patients' condition on their discharge from hospital. Letters have been
sent to the patients, and questions have been asked with regard to their
progress and present condition. Many replies have been received. An
attempt has been made to classify the results into one of the following
groups : —

(1) Perfect recovery ; (2) very good recovery ; (3) good recovery ; (4)
moderate recovery ; (5) bad recovery : (6) very bad recovery. Opinions,
no doubt, would differ as to which ought to be considered a good and
which a bad result; the patient's opinion with regard to the result has been
allowed to have full weight, and the severity of the primary lesion has also
been taken into consideration. No case of (1) "perfect recovery" has
been obtained. If the patient can follow any occupation and has little
disability the result has been considered to be (2) " very good." The
result has been considered to be (3) " good " if the patient has been
retained in the Army and classified into a group, or has showed signs of
commencing recovery within six months from the date of operation.
(4) " Moderate " results are those in which the limb is considered to be
much better than an artificial one, but the disabihty is nevertheless
considerable. (5) " Bad " results are those in which the limb is of very
little use, but is still as good or better than an artificial limb. (6) "Very
bad " results are those in which the limb is practically useless, and are the
cases in which amputation must be considered.

Tables have been drawn up showing the number of cases operated
upon. The various nerve lesions have been classified in a tabular form,
and an attempt made to show the results obtained up to the present
time. From a study of these cases the following are the conclusions
arrived at : —

(1) That the diagnosis of an injury to a peripheral nerve ought to be
made at the earliest possible time.

(2) Successful recovery depends upon early, correct, and continuous
treatment.

(3) Primary suture should be considered and practised whenever
possible.

(4) That there should be no unnecessary delay in exploring a nerve if
there is sufficient evidence that it has received some injury resulting in a
macroscopic pathological lesion.

(5) It is almost certain that some macroscopical lesion is present in
cases which show no signs of recovery after four months' treatment.

(6) That operations on injured ner/es should only be done in w^ell-

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C. Noon

equipped general hospitals, and by those surgeons who have ample
experience of such cases.

(7) That sufficient attention is not usually paid to the early pre-
operative and post-operative treatment in paralytic deformities, and
shortened muscles are often the result of ignorance and neglect.

(8) That the extreme gravity of an injury to a peripheral nerve is not
sufficiently realized by the general profession.

I wish to acknowledge my indebtedness and appreciation to Colonel
T. H. Openshaw, Consulting Surgeon to the Eastern Command, for his
advice in some of the more difficult cases, and I also desire to thank Major
Cleveland and his staff in the electro-therapeutic department of the
hospital for numerous suggestions in the treatment of the cases.

The following table shows the total number of nerve lesions which have
<;ome under observation, and their relative frequency.

Ulnar

Median

Musculo-spiral and post-interosseous . .

External popliteal

Lesions of the brachial plexes

Combined lesions to the median and ulnar

Anterior tibial

Circumflex , .

Internal popliteal

Posterior tibial

Sciatic

Anterior crunal

250

REFERENCES.

Delorme. Rev, de Chir., 1915, xxxiv, p. 402.

Hernaman-Johnson. Brit. Med. Journ., July, 1915.

Jacobson. " The Operations of Surgery."

John Fairbairn Binnie. " Manual of Operative Surgery."

Jones. Brit. Med. Journ., May, 1916.

Lyle, H. H. M. Surg. Gynccc. and Obst., 1916, xxii, p. 127.

Langlet. Brit. Med. Journ., January, 1918.

Moynihan. Brit. Med. Journ., November, 1917.

ScHiFFBUNER, H. E. Siirg. Gynac. and Obst., 1916, xxii, p. 133.

Stopfobd, J. S. B. Lancet, 1916, cxc, p. 718.

Smith. Brit. Med. Journ., June, 1916.

TuFFiER, T. Bull, et Mem. Soc. de Chis. de Par., 1915, xii, p. 1911.

Thomson and Miles. " Manual of Surgery."

THE PROPHYLAXIS OF MALARIA. .

By Colonel G. T. KAWNSLEY, C.B., C.M.G.
Lieutenant-Colonel E. A. CUNNINGHAM.

Royal Army Medical Corys.

AND

Captain J. WAENOCK.
Royal Army Medical Corps.

PAET I.
By Colonel G. T. RAWNSLEY.

In the Practitioner for the month of October, 1917, the interesting
statement appears that Mitzmain^ has carried out an important investiga-
tion for the United States Pubhc Health Service on the problem whether
the mosquito or man is the winter carrier of the malaria parasite.
Amongst his conclusions are : —

(1) Only the adult female mosquito of anopheles hibernates.

(2) Anophelines were found negative for malarial parasites in winter.

(3) Man was largely infected with the malaria parasite and about one-
fourth (24'8 per cent) of the human carriers harboured gametocytes.

(4) Three infected Anopheles quadrimaculatiis were found in the houses
of gametocyte carriers during May 15 to 26 ; previously thereto 1,180
specimens were negative.

The conclusion was thus arrived at that man is the sole winter carrier.

So far no other forms of animal life, except man and the anopheline
mosquito, have been found by investigators to be carriers of the malaria
parasite.

If we admit the accuracy of these statements, the lines indicated for
the prophylaxis of malaria resolve themselves into the destruction of the
parasite in man and the destruction of the female anopheline mosquito
which alone with man is a harbourer of the malarial parasite.

It would appear therefore the best way to attain this end, as far as
man is concerned, is by carrying out the necessary treatment, in a country
where there is a malarial and a non-malarial season, in the winter months.
The reasons which lend support to this view are : —

(1) There is a smaller incidence of malaria, primary cases being absent.

(2) Reinfections are non-existent owing to inactivity of the mosquito.

(3) If the major part of the population can be freed from the parasite,
when the next malarial season starts fewer carriers of infection are
present. If the treatment is begun sufficiently early relapses will indicate

' Llitzmain. Public Health Bulletin, No. 84, 1916 (Treasury Department, U.S.A. Public--
Health Service). ^

G. T. Bawiisley, B. A. Cunningham and J. Warnock 61

who are carriers and who are not, and it should be easy in an army to
remove those who are a source of danger by sending them out of the
country before the onset of the summer and the period of renewed
mosquito activity.

The prophylactic measures adopted in this army were as follows : —

(1) In 191G .—

(a) Prophylactic quinine was given in five-grain doses twice weekly,
usually on two consecutive days. It was quite useless to prevent a very
high occurrence of malarial fever.

(b) Pieces of netting about one yard square were used to cover the face,
but not being mosquito-proof were naturally ineffectual. Subsequently
the size was increased to six feet by four feet, and in places where they
could be used hospital pattern nets were issued.

(2) In 1917 :—

(a) Prophylactic quinine has been given in varying doses : ten grains
twice weekly on Thursdays and Sundays, every other day, four days
weekly and every day. In fifteen-grain doses daily and in twenty-grain
doses daily. These doses have all failed to confer prophylaxis, in fact,
I look upon the larger doses as positively dangerous. The smaller dose
probably does not as a rule check pyrexia, and so the man reports sick for
fever, his disease is recognized and he comes early under effective treat-
ment ; but the larger amounts, that is a dosage of over and above ten
grains twice weekly, have in my experience in a very large number of
cases fulfilled the anti-pyretic action of the drug without destroying the
malarial parasite. In many regiments treated in this way we were lulled
into a sense of false security by the absence of pyrexia and later on many
men who had never reported sick were found with enlarged spleens,
ansemia, palpitation and all the symptoms of malarial cachexia. Thus by
these methods the men became a source of danger in spreading infection,
and the quinine instead of having a prophylactic effect had exactly the
opposite, as it failed to destroy the parasite, and so the man became a
gametocyte carrier capable of infecting mosquitoes. Many of the units
treated with doses of quinine over ten grains twice weekly were the worst
sufferers from malaria this year. I do not consider such doses have any
effect on making the parasite quinine-resistant, but my experience is that
the strength of the quinine solution in the blood is not sufficient in the
doses aforementioned to destroy the parasite. Later on in this paper I
shall give further reasons for this opinion.

ib) A bivouac mosquito net was used. This certainly afforded large
protection and was an undoubted factor in the prevention of malaria. An
improved type is being adopted for 1918. ^

(c) Head net veils and gloves for men on night duty. These were not
popular ; men complained of difficulty in seeing and of handling their arms
and in many cases they were discarded.

(d) Kepellant ointment is undoubtedly useful if it is replaced very
frequently during the hours men are exposed on night duty.

The Prophylaxis of Malaria

Divisions.

Malaria practica

ly only affects th

1916

ese rat

ss : —

I'.a;

May

0-20

0-24

June

0-31

0-28

July

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0-50

August

0-4G

0-42

September . .

0-75

0-55

October

0-47

0-54

November

0-25

0-34

(e) Other anti-malarial measures having for their object the destruction
of the mosquito.

In 1916, owing to the advanced state of the season, when we took over
our present front little was done in this respect, but this year extensive
drainage, canalization, oiling, clearing of brushwood, scrub and rank
vegetation and burning of grass, etc., in the vicinity of camps, have been
carried out with undoubtedly good results.

(/■) Pitching camps on as high ground as possible and away from known
malarial sites.

The result of these methods is shown by a co;uparison of the average
daily sick rates for all causes per month as under for the same two

The slightly higher a'ates for October and November, 1917, are due to
the fact that in 191(5 all malarial cases were evacuated from the country,
whereas in 1917 they have been treated here, therefore these rates include
a higher proportion of relapses. But satisfactory as these results are it
appeared to me that more might be done, and with this end in view I
considered the advisabihty of putting troops on a much higher dose of
daily quinine, viz., thirty grams daily. Captain D. Thomson, R.A.M.C,
in his paper in the Journal of the Eoyal Army Medical Corps stated
this should be given in hospital, keeping the man in bed the first week, up
in the ward the second week, and taking gentle exercise out of doors
during the third week. But hospital treatment except for men with high
temperatures or otherwise needing admission would not be feasible in the
case of large numbers of men suffering from chronic malaria in an army
in the field. I therefore received permission to start a small camp for 100
men ; these men were under ordinary conditions except that they performed
no large amount of work. They went for walks and did all the fatigues of
their camp. The treatment given was thirty grains of quinine in mixture
daily as follows : —

'^ Quinine sulphas . . . . 10 gr. or, Quinine bihydrochlor. . . 10 gr.

AquEB . . . . . . ad 1 oz. Acid hydrochlor. dil. . . q.s.

Acid sulpb. dil. .. .. q.s. Aquse ad 1 oz.

Thrice daily, further well diluted with water, within five minutes of each

meal, i.e., breakfast, dinner and tea. An iron, arsenic and quinine tabloid

was also given at the same time, the composition of which is :-—

"^i Iron hypophosphite . . . . . . 2 gr.

Acid, arsenious, B.P.
Quinine bisulphate
Strychnine sulphate
Saccharine, B.P.

G. T. Rawnsley, B. A. Cunningham and J. WaynocJc 63

The clinical results were rapid and exceeded all expectations, there were
no untoward symptoms, such as deafness, altered vision, etc., and from
the rapid disappearance of ana3mia and the healthy colour which appeared
in its place, it was easy to pick out new arrivals from those who had been
some few days in camp. Even after five days the improvement was
marked.

Being satisfied with the success of this treatment and that it had no
ill effects on the men, it was resolved to continue treatment in other cases
and under different conditions ; in the one instance fifty-one men who
were known to be badly infected with malaria were camped near a
casualty clearing station and kept as nearly as possible under service
conditions, doing route marches and fatigues, and about the same amount
of work as they would have done in the front Hne. They lived in bivouac
tents with mosquito nets, and during a great part of their stay the weather
was very variable, being wet with cold winds, conditions which should
have been favourable to chill and consequent malarial relapse. While
here advantage was taken of the proximity of a Bacteriological Laboratory
and an Ophthalmic Centre, for the purpose of carrying out observations
appertaining to the state of the blood and the condition of their eyes.

Two medical officers, Captain W. H. Peacock, E.A.M.C., and Captain
T. H. Comerford, E.A.M.C, gave most valuable assistance in closely
watching and supervising the progress of treatment. No unfavourable
symptoms were observed in any of these men by either of these officers,
nor by myself as the result of frequent inspections. No defects of vision
or hearing were observed. Anaemia soon vanished, the haemoglobin rose
in the blood and parasites disappeared microscopically, the spleen went
down in size and the men became robust, vigorous and active. Nearly all
the men increased largely in weight and previous results were confirmed.
These fifty-one men were given no quinine for first few days of their staj'
at the casualty clearing station before treatment was commenced and
fifteen of the number suffered from relapses of malarial fever and in many
the parasite was found in their blood during this time. They took
bihydrochloride of quinine.

In the other instance a company of a battalion was placed, at my
request, on the same treatment by Lieutenant-Colonel R. A. Cunningham,
R.A.M.C., whose report is added (Part II). This company remained doing
full duty in the trenches, and subsequently, at the expiration of their tour
there, in the support line. They took the treatment as v^ill be seen
without any unfavourable symptoms, but on the contrary with marked and
beneficial results.

Two men out of the original fifty-one of the first observation had to
remain on under treatment ; one man still had the malignant parasite in
his blood, but after a further period of treatment this had disappeared
microscopically ; the other man was suffering from an irregular atypical
pyrexia, no parasite being found in his blood, but on the cessation of quinine

64 The Proplnjlaxis oj Malaria

the malignant parasite was found in moderate numbers. No other man
*out of this number nor amongst the cases of the second observation
treated by Lieutenant-Colonel Cunningham has so far had a relapse.

Allusion may now be made to the opinion previously expressed that
smaller doses of quinine up to twenty grains do not make the parasite
quinine-resistant. The result of the treatment of thirty-grain doses daily
was followed by immediate, very rapid and marked improvement in men
well dosed the whole season with quinine ; the blood tests showed by the
early disappearance of the parasite and the rapid rise in the haemoglobin
that no powers of quinine resistance had been conferred on the parasite
when sufficient and effective doses of the drug were given, and one would
not have expected to attain these results so speedily had such been the
case, and the credit must be given to the production of such alterations in
the blood to the activity of the drug.

The course of treatment recommended and which will be further
observed is to put a company of a regiment at a time on thirty grains
quinine daily for a period of twenty-four days. Men after four weeks
begin to suffer from quinine intolerance.

Points to bear in mind are that the mixture should be well diluted in
at least an ounce and a half of water, and administered immediately after
a meal — the longer interval that elapses the more chance there is of
intolerance to the drug. It should be given twice daily in fifteen-grain
doses morning and evening ; three minims of liquor arsenicalis hydro-
chloricus may be added to each dose, but Fowler's solution should not be
used, as this preparation in an acid solution is liable to deposit the arsenic
to the bottem of the bottle and a dangerous dose of arsenic may thus be
given. The tablet of iron, arsenic and quinine is also a useful adjunct to
treatment in place of the liquor arsenicalis hydrochloricus in the mixture.
Another precaution is that the solution should be measured in a dispensing
measure-glass, and tablespoons and other such measures not employed,
as inaccuracy in dosage is bound to occur.

It has been found by Lieutenant-Colonel Cunningham, E.A.M.C,
that healthy men stand this dosage as well as, if not better than, those
suffering from malaria, and also in a further observation on my part ;
consequently the conclusion arrived at is that in very unhealthy portions
of a line troops should only remain twelve days at the most and during
this period should receive a daily dosage of thirty grains of quinine; this
idea will be further developed during the next malarial season. Further,
from a result of. experience of two malarial seasons in Macedonia, my
experience in West Africa, India and the West Indies is enhanced that : —

(1) Prophylactic quinine as now given is useless if not dangerous in
the prevention of malaria, as it so frequently only masks the disease.

(2) That the proper prophylactic dose is one of thirty grains daily, but
this cannot be given for a longer period than four weeks.

(3) That a smaller dosage of quinine does not render the parasite
quinine-resistant.

G. T. Raivnsley, B. A. Cunninghatfi and J. War nock 65

(4) Prophylaxis should aim chiefly at destroying the mosquito and its
larvtu, and protecting man from its bites, and when man becomes infected
destroying the parasite by suitable doses of quinine, especially during the
post-malarial season.

In the case of troops every officer and man who has been exposed to
malarial infection should undergo a winter prophylactic course. In this
connexion Colonel Sir M. P. C. Holt recently told me he had the blood
examined of many men in this country with no record of malarial fever
and found many of them infected with the parasite.

(.5) The destruction of hibernating mosquitoes. The experience here
so far is that only the female hibernates.

(6) Larvae have also been found in the winter in Macedonia beneath
the ice. Measures therefore for their destruction must also be taken.

Observations as to the effect of thirty grains of quinine daily on the
blood of healthy men have also been made by Captain J. Warnock,
R.A.M.C., and are included in his Report (Part III).

I am indebted to Captain H. E. Smith, R.A.M.C.(T)., for the following
report on the condition of the eyes and the state of vision of the fifty-one
men under observation at the casualty clearing station : —

" I have concluded the ophthalmic examination of the fifty-one post-
malarial cases under special quinine treatment at the casualty clearing
station. The cases were examined during the first and last weeks of the
treatment, and the points investigated were : —

" (1) The visual acuity.

" (2) The white and colour fields.

" (3) Subjective symptoms, e.g., transient obscuration of vision.

" (4) Ophthalmoscopic examination ; (a) colour of optic disc ; (6) size
of vessels ; (c) any other abnormality.

" I have to report that there was no complaint of defective sight, no
objective deterioration of visual acuity, and no evidence of change in the
field or fundus in any of the cases."

One half of the men who had been treated both at the casualty clearing
station and by Lieutenant-Colonel Cunningham have continued quinine
in fifteen-grain doses daily, the other half have had no quinine.

The men from the casualty clearing station, with two exceptions,
returned to duty with their regiments on November 15, 1917, four weeks
ago. A few days before leaving, a team of eleven of these men played the
casualty clearing station at football and won their match by 7 goals to 2 ;
they played with vigour and showed no signs of distress during the
same.

66 The Prophylaxis of Malaria

PAET II.
By Lieutenant-Colonel E. A. CUNNINGHAM, E.A.M.C.

Malaria is an infective .disease which is spread from one man to another
by means of anopheline mosquitoes. Reducing the number of infected
persons in a community is one of the methods of lowering the incidence of
the disease. Owing to the absence of the civil population, infection in the
front line area is chiefly derived from the troops themselves. If, therefore,
it were possible to make a large proportion of the troops non-infective
before the next malarial season begins, it would greatly assist in reducing
the incidence of malaria.

With this object in view, Colonel G. T. Kawnsley, D.D.M.S., of
the Corps, undertook a series of observations as to the effect of the
administration of thirty grains of Quinine daily for a period of from three
to four weeks in permanently curing the disease, and so preventing the
formation of carriers. If this treatment was to be applied as a practical
measure to the whole Corps, it was necessary to prove that it could be
carried out whilst the men were actually engaged in their ordinary duties
with their units. At his request, therefore, I carried out a course of
treatment in "X" Company, the most highly infected company in a
badly infected battalion. Almost every man in the company had had
malaria, and as it was impossible to say which men were or were not liable
to relapses, all the men in the company who were present on October 10,
1917, with one or two exceptions, were put on the treatment. Each man
received 30 grains quinine daily, 15 grains quinine sulph. in solution
diluted to Ih ounces being given every morning and evening after meals.
During the second week two minims Fowler's solution were given with
each dose, and during the fourth week three minims. As new drafts joined
the company from hospital or elsewhere, they were also put on this treat-
ment. The total number of men who received this treatment between
October 10 and November 6 for at least three weeks was 104 ; of these
eighty-eight received it for the full four weeks.

The following figures show the results of treatment : —

(1) Total number of men who had the treatment for at least three weeks . . . . lOl

(2) Number of men who were sent to the Field Ambulance with fever between

October 10 and November 6, whilst taking 30 grains quinine daily . . . . 2

These two men wer6 sent to the Field Ambulance within the first few days after
the treatment began.

(3) Number of men who were sent to the Field Ambulance with fever from the rest

of the battalion (numbering about 500), between October 10 and November 6. . 80
The whole of these men had been on 10 grains daily for the last three months.

In addition to the men sent to hospital during this period, October 10
to November 6, a large number of men in the rest of the battalion had
mild relapses, and were treated regimentally. Ampng the 104 men
receiving the special treatment, only six had slight rises of temperature,
and this was at the very beginning of the treatment. Three ofticers of

G. T. Bmonsleij, B. A. Cunningham and J. Warnoch 67

*'X" Company who were not on the treatment had fever between
October 10 and November 6.

From October 10 to 25 the men receiving the special treatment were
in the front Hne, and were doing the ordinary wor-k of the battah"on— sonje
digging, some on outpost, some wiring, etc. Two platoons were in a
fort in the front line from October 14 to 25, and during this period no
man in these two platoons had fever or was off duty, although each man
was on outpost duty every other night, and the weather was frequently wet
and cold.

On October 25 the company moved back to a camp in support, and
although the day had been very wet, and the men had to bivouac on wet
ground when they got to camp, no one took fever in consequence.

The men have improved very much in appearance and health, and have
lost the anaemic look that they had. They are at present doing training,
road making, route marching, etc., and play football with much vigour
after the day's work. Many of them also took part in the regimental
sports— running, jumping, tug-of-war, etc. They went back again into the
front line on November 7.

During the course of treatment I saw the quinine administered, inspected
every man morning and evening, felt his pulse, and inquired how he was.

In a very few cases I reduced the dose to twenty grains on account of
slight buzzing and slight deafness, but it was not really necessary to have
done so. In one or two cases I gave men tabloids instead of solution on
account of shght indigestion. Two of the men towards the end of the
fourth week of treatment complained of slight giddiness, and I stopped
their quinine. Apart from these few cases all the men took the quinine
without the slightest inconvenience, including fourteen men who had never
had malaria.

The following are some details of the previous history of the 104 men
who received the treatment : —

(1) Number who had been in hospital with malaria . . . . . . . . 45

(2) Number who had had fever, but were treated regimentally . . . . . . 44

(.3) Number who had never had fever . . . . . . . . . . , , 14

Total . , . . 104

Details as to relapses in the ninety men who had had fever : —

(1) Number who had had numerous relapses prev

special treatment

(2) Number who had had two relapses . .

(3) Number who had had one relapse

(4) Number who had had no relapse

ious to the commencement of the

6
6

25
53

Total

The observation is being continued as follows : —

The administration of quinine to the fourteen men who never had
malaria has been stopped.

As regards the remaining 90, 2 men have gone away, which leaves 88.

68 The Prophylaxis of Malaria

The administration of quinine to 44 of these has been stopped. The
other 44 are to receive 15 grains quinine daily for one month, and then
10 grains daily for another month.

The number of relapses which occur in the first forty-four will be com-
pared with the number occurring in the second forty-four.

A roll of the men has been made, and any case of fever which occurs
among them, whether treated regimentally or admitted to field ambulance,
is notified.

During the month of November seventy-two cases of malaria and
N.Y.D. pyrexia were admitted to field ambulance from the rest of the
battalion, and none from the men who underwent the treatment. One of
the men had a slight rise of temperature on November 30, and he is being
treated regimentally.

These results are exceedingly striking. In eight weeks there was
practically no pyrexia among the 104 men of "X" Company, although
this was the worst infected company in the battalion, while from the rest
of the battalion, during the same period, nearly 150 men were admitted to
hospital with malaria and N.Y.D. (pyrexia), and numerous others were
treated regimentally. <

There is no reason to suppose that what happened in this company as
the result of the treatment would not also approximately happen in a
whole battalion, a whole division, or a whole corps, if the treatment were
as thoroughly and carefully carried out ; and I have no doubt that if this
were done the number of relapses occurring in the spring months would
be immensely reduced. A roll could be kept of the men who resisted the
treatment and remained carriers, and they could either be sent out of
the country Or kept at the base, or on the lines of communication, where
the presence of carriers is not of so much importance, as there is already
an infected native population there. If this were done, it would greatly
reduce the number of infected anophelines in the Corps areas, and con-
sequently lessen the incidence of malaria.

PAET III.
By Captain J. ^YARNOCK.

Royal Army Medical Corps.
0. i.jc. Mobile Bacteriological Laboratory.

Laboratory Notes on Malaria with special Keference to the
Treatment of a Series of Unselected Cases.

The series of cases considered was chosen under the direction of Colonel
G. T. Rawnsley. Each man had a clear past history of clinical malaria,
and was so selected as to be roughly a sample of the malarially affected
troops.

The treatment adopted was -a continuous twenty-eight days' quinine
course of thirty grains daily combined with arsenic in small increasing doses.

G. T. Bawnsley, U. A. Cunningliam and J. Warnock 69

The usual methods of investigation have been employed throughout,
and conclusions drawn from the consideration of this special series as well
as from the routine examination of the many thousand specimens which
the material of this army has provided.

The points considered have been : —

(1) Continuous clinical records of temperature, pulse, weight, etc.,
among the fifty-one special cases.

(2) Untoward effects of quinine, if any, such as vomiting, giddiness,
deafness, defects of vision, etc.

(3) Laboratory examinations directed to the condition of the blood and
the study of the malarial parasite.

Control examinations were made in a number of " healthy " men chosen
so far as could be determined from amongst those who had not had malaria
and who had served only for a short period with this army.

As an introduction to the detailed account, some general observations
may be made on the malarial question as it arises here.

(a) The whole natural picture of malaria has been necessarily clouded
by the complication of quinine treatment.

(6) Malarial patients are often much more seriously debilitated, even
after a few attacks, than the blood examination would suggest, and
conversely the blood will often show an enormous number of cells invaded
by the parasite with no corresponding clinical gravity of effect.

(c) All three classical types of malarial parasite have been found. The
quartan parasite has been extremely rare but the benign and malignant
tertian parasites have been \iniversally prevalent and a seasonal variation
has been strictly observed.

In the early months of the year, benign tertian alone was seen and
ganfete forms were relatively frequent ; with the advance of summer
however the gamete forms became less and less in evidence, but again
increased in proportion with the commencement of the winter.

The malignant tertian parasite appeared about mid-July and increased
in prevalence through the hotter months, declining in numbers with the
autumn temperature, though still accounting for most of the severe cases
until toward the end of November, when the benign parasite in " relapse
cases " became again the common type.

It may be added that thick-and-thin film methods of examination have
been employed, and that thin films have been found most generally useful,
thick films being, however, the method of choice for the discovery of
pigmented, more especially the crescent, forms.

{d) Quinine treatment and diagnosis. Malarial pyrexia is so generally
reduced by moderate doses of quinine, e.g., thirty grains daily, that a
temperature over 99" on the fourth day is a practical exclusion of malaria.

The response, or absence of response, to quinine treatment is therefore
practically decisive from the point of view of diagnosis. This statement
refers to the "ordinary case," and qualifications will be dealt with later.

70 The Prophylaxis of Malaria

(e) Quinine in moderate doses quickly banishes asexual parasites from
the peripheral circulation, so that, often after one dose, and usually after
three doses of ten grains, microscopic diagnosis becomes very tedious.

The gamete forms are not so influenced, but their numbers are not
generally great.

Following these general statements some detailed figures may be given
of the results of the inquiry into the effects of the combined quinine
and arsenic treatment carried out under more or less active service
conditions.

I- — Clinical Records. — These may be shortl}' summarized : —

(a) There was no difiiculty with continuous administration of quinine,
and no unpleasant effects noted beyond very slight vomiting, easily
corrected, which occurred in a few cases in the fourth week of treatment.

(b) All the men looked better with two exceptions ; one case (malignant
tertian) will be detailed later", and the other was under special vaccine
treatment for boils.

(c) An average increase of weight of five pounds was recorded. In
only five cases was a decrease noted ; two of these were the cases men-
tioned above, and the decline of the others (two pounds) was so slight
as to be negligible.

(d) Cardiac response to exercise was much more healthy at the end of
treatment than before.

II- — Laboratory Examinations. — Attention was directed to: —
{!) Discovery of the parasite and inquiry into its reaction to quinine
medication.

(2) Haemoglobin estimations.

(3) Counts of red and white blood cells.

(4) Differential counts of white cells.

(5) Inquiry into a possible fragility of the red cells of men undergoing
quinine treatment and a possible haemolytic action of the serum,

(1) The malarial parasite was discovered in nineteen out of the fifty-one
cases (M.T. 6, B.T. 9, ? type 4) ; two of these cases were continuously
apyrexial and two others only once reached 99". In general, it may be
stated that benign tertian parasites are not often found in the apyrexial
period during the season of prophylactic quinine.

It has been determined, however, by a commission working under the
direction of Lieutenant-Colonel L. B. Dudgeon, Consulting Bacteriologist
to this army, that during the winter months a careful search will reveal
the parasites in apyrexial " malarial carriers " in a considerable percentage
of the cases.

In one of the fifty-one cases crescents were found up to fourteen
days after commencement of quinine treatment ; such a discovery of
crescent parasites after the period of treatment with thirty grains daily
has been a common observation.

In a second case crescents, in small numbers, were demonstrated up to
forty-six days' treatment.

G. T. Baivjisley, B. A. Cunningham and J. WarnocJc 71

In no case were asexual parasites found after three days' treatment.

The effect of quinine treatment in the pyrexia of malaria has already
been referred to and a general diagnostic rule laid down.

Qualifications of this rule must be made, however, in the many severe
cases of malignant tertian malaria which have been, throughout the
autumn, far from uncommon.

Fever of four, five, or six days' duration, with occasional irregular
slight rise of temperature afterwards, is a common occurrence as an almost
typical eight days' chart of a " moderately severe " case here presented
would show.

OAYofOIS

A-

F°
1 0 5°
1 0 4°
1 0 3°
10 2"
10 1°
1 OO'
9 9°
9 8'

M C

M E

:>^

VJA

%.'■'

Chart 1.

In addition to these more usual types of case, rarer cases of more or
less continued slight pyrexia occur on which quinine treatment would
appear to have very little influence.

One such case occurred amongst the special series of post-malarial
cases dealt with, and a chart with details is given. In this case no
parasite was discovered, in spite of very many repeated examinations
both at the beginning and during the progress of treatment. .

This negative consideration, and also the absence of a palpable
spleen and the existence of a high leucocytic count (9,000 to 13,000),
combined with the irregular pyrexia, led to the alternative suggestions of
oral sepsis, enterica and tuberculosis, for all of which hypotheses diagnostic
procedures were employed with negative results.

After six weeks' continuous treatment (thirty grains daily) quinine was
abandoned and in five days numerous malignant tertian rings appeared in
the peripheral circulation coincident with a "bilious" vomiting and a
typical attack of malignant tertian fever. Quinine was then again resumed
in larger doses (forty-five grains daily), the first dose being intramuscular
owing to the vomiting; the condition, however, seems to have been more
or less controlled, but not shortened by the treatment.

(2) Haemoglobin estimates : Figures here are restricted to the small

The Prophylaxis of Malaria

series of fifty-one selected cases and the results have been extremely
striking. A rapid rise in haemoglobin value was immediately obvious,
corresponding with the improved general appearance and physical fitness
of the men.

CHART OF CASE 28.

OCT.

DATE

25|26

10 1°

10 0°

9 9°

9 8°

9 7°

M, F

iM F

M E

M C

M E

•

j'^

■A

-7-'

-'-

I /

■

/ i

■

■ ^

M.^

t \

l/^

¥:

■

PULSE

72
72

72
78

66
106

97
96

60
90

8-^

80
120

114

78
108

60
104

72
106

84
.96

88
120

92
102

87
111

78
84

102

96
150

DATE

F°

10 2°

10 1°

10 0°

9 9°

9 6°

9 7°

M F

M R

M E

' t

;

'■■h

.A.

-i'—

rr-

-r-

Ij'

k/^

, /

<j'

\/'

> A

PULSE

lie

123

96
_I32

86
117

88
112

88
120

92
120

93
126

104
144

99
112

92
102

88
120

116

84
132

96
132

108
108

117
124

120
128

99
90

84
70

82
112

70
122

NOV

DEC

DATE

M E

M C

M E

Wl E

F°

1 0 3°

10 2°

10 1°

10 0°

9 9°

9 8°

9 7°

■1

1^'-

~,r-

Irr^

"■^

lv^

v»

88
116

102
128

116
88

88
98

92
92

88
108

78
100

100

104
120

98
110

90
80

76
80

72
76

80
79

76
79

79
98

86
110

96
107

94
118

PULSE

The average increase was fourteen per cent at the end of treatment,
but the closest grouping of figures approximated to 17"5 per cent, and this
may be taken as what might be termed the " expectation of improvement."

Extreme cases of thirty per cent and forty per cent increase were
recorded.

G. T. liaw/isleij, B. A. Cunningham and •!. Warnocl- 73

Comment may be made on the fact that most of the cases at first had
haemoglobin estimations of 70 to 75 per cent, while a series of normal
men gave values 85 to 90 per cent.

This difference in oxygen-carrying capacity of the blood is not enough
to account for the obvious physical unfitness affecting nearly the whole
series examined and would suggest that the malarial organism produces its
effects more by a general toxajmia than by a limited destruction of the red
blood cells. That this is so is evident.from the intense tissue destruction
found post mortem in practically all the fatal cases, even when macroscopi-
cally, beyond enlargement in the spleen, there may be no obvious disease
or cause of death.

(3) Eed counts : In the special series considered, an increase parallel to
the increase in haemoglobin was observed. The average increase was
fourteen per cent.

White cell counts : Observations were, for the sake of comparison, made
always at the same time of the day, but owing to the known normal varia-
tions actual figures are of little value. Hence general conclusions may be
given to which it was found that the small special series also conformed.

In the apyrexial period counts below 3,000 or above 9,000 are not
common, while 4,000 to 6,000 would appear to be the general rule.

During an " attack," a more marked leucopenia is often found, but the
exceptions are so common that this can scarcely be accepted as a rule ; it
would appear that very low counts only occur if there is marked anaemia,
while if the attack is resistant or severe a high count is more likely to be
found.

(4) Differential counts of white blood cells : These estimations again
made over a large number of cases have given interesting results.

The figures may be best presented by considering definite illustrative
series. Only three cell types for the moment are considered.

Average pnrcentase count of cells

Polyinorpho- I.ympho- I-arge "

nuclear cytes hyalines

Series 1.

Fifty cases of benign tertian fever during .. 54 .. 27 .. 17

an attack and before commencement
of quinine treatment
Series 2.

Fifteen cases of malignant tertian, also .. i4 .. 31 ,. 23

during attack and before quinine
Series 3.

Twenty-five cases of unverified malaria, . . 58 . . 24 . . 16

during attack and before quinine
Series 4.

Fifty cases of afrebrile " iJost-malaria" .. 45 .. 34 .. 19

cases during treatment with quinine
Scries 5.

Fifteen cases where malaria could be .. 45? .. 42 .. 10

practically excluded

74 The Prophylaxis of Malaria

Comment on these figures as regards the deviation from the normal
is unnecessary, except for the inclusion of the last series, which was strictly
chosen to exclude malaria but to include men who had served for at least
one summer in this country.

It will at once appear that an increased percentage of large hyaline
cells is of little diagnostic value in malaria ; since a similar phenomenon
appears to be produced by climatic or other causes amongst healthy troops
serving with this force.

The numerical differences above detailed are not the only deviations
from the normal, for not only is the total mononuclear count increased,
but the type of cell differs widely from that found in health. Typical
lymphocytes and large hyaline cells are found, but there are also present
types not seen in normal blood, but occurring in the bone marrow and
the spleen. Typical myelocytes are sometimes found and large finely
granular mononuclear cells suggesting gradations between true myelocytes
on the one hand and polynuclear cells and large hyaline leucocytes on the
other. The number of these cells varies and appears to have some relation
to the severity of the case. The actual number has not been noted above
five per cent of the total white cell count.

A further malarial abnormality is the presence of the characteristic
pigment in the large hyaline and polymorphonuclear cells. This occurrence
has been looked for over a series of several thousand specimens, and while
pigment in both types of cell has been occasionally seen the examples
have been so extremely rare that the observation can have no value in the
diagnostic sense. The conclusion, therefore, drawn from this method of
inquiry has been that a microscopic diagnosis of malaria must, for all
practical purposes, be based entirely on the discovery of the parasite.

(.5) Inquiry into a possible quinine-induced fragility of red blood cells or
hsemolytic action of the serum.

That quinine treatment may damage the red cells in ordinary cases
and even under special circumstances predispose to, or cause, blackwater
fever has been often stated. Barret and Yorke have proved that quinine
in dilution approximating to that ordinarily present in the circulating
blood after administration has no haemolytic action on washed red cells.

Sampson and Edie have, in a short series of men and animals,
determined the tota/i- excretion of urobilin and have hence deduced a
probable haemolytic power. Their series, however, has been so short an(J
the results so varying, that any conclusions must be uncertain.

Our examinations have been limited to thirty cases. A small but
almost constant difference has been found amounting to 0-025 per cent
in the strength of saline which just produced haemolysis, to this extent
the series treated having less fragile cells than the series of " controls,"
and in the same sense the serum observations have discovered no hsemolytic
action, the deviations from control figures in the few cases which occurred
being in the direction of protection of the cells. The numbers, however.

G. T. Razvnslei/, R. A. Cunningham and J. Warnock 75

so far examined have been too small from which to draw definite con-
clusions, beyond the fact that any untoward influence of quinine in the
blood, if present, must be very slight, and is probably more than counter-
balanced by the conjunction of arsenic.

Summary.

For the sake of clearness, conclusions may be summarized regarding
the possibilities of the standard quinine treatment.

(1) No deafness, visual defects or other disadvantages are likely to
accompany or follow the administration of quinine thirty grains daily
for three to four weeks.

(2) The general health and physical fitness of malarial cases so treated
will markedly improve under treatment.

(3) Arsenic is a valuable adjunct to quinine in the treatment of malaria.
-(4) Few relapses are likely to occur and fresh infections can be dealt

with as they arise (no relapse, excluding one uncured resistant case,
occurred amongst the special series treated, after four weeks of very severe
weather since cessation of the treatment).

(5) The malignant tertian parasite would appear to be the most resistant
type. Relapse cases occurring in the early months of the year are
generally benign tertian ; it is probable, therefore, that a three to four
weeks' course of thirty grains daily will cure a considerable proportion of
the men so treated.

(6) A possible difference in the parasite found in this country from that
seen elsewhere has been often mentioned. It would seem probable, how-
ever, that the different effects produced may be due to indefinite and
irregular quinine administration.

{To he continued.)

(Tlinical anb otbcr IRotes.

ANESTHETICS IN THE FIELD.
By Captain W. K. H. HEDDY.
Boyal Army Medical Corps (T.).
Late Assistant Antesthetist (Resident) Middlesex Hospital.

Comparatively few surgical operations are now performed in the immediate
vicinity of the firing-line, since it is the routine practice to evacuate cases requiring
operative treatment to the casualty clearing station with all possible speed.
There are, however, circumstances in which the administration of anaesthetics to
patients in field ambulances may be indicated, and it is the purpose of this article
to discuss briefly the conditions in which the employment of anaesthesia may be
useful and to give a short account of the equipment available.

It well be well to deal initially with the question of equipment. The most
important items of the anaesthetic outfit are contained in field surgical pannier
No. 1, which includes among its contents chloroform (three pounds) in sealed
glass tubes, two drop-bottles, a hypodermic case with the essential drugs, and an
excellent saline infusion apparatus. Further supplies of chloroform (one pound)
are to be found in field medical pannier No. 1, together with a spare drop-bottle
and a reserve set of hypodermics. Medical units in the field have lately received
certain additional articles of operative equipment in the shape of an " outfit,"
which includes among other things a mouth-gag, tongue-forceps, and a Skinner's
mask. Ether is also now available, while should the administration of oxygen be
urgently indicated, even this commodity will frequently be at hand, though it
must be remembered that oxygen cylinders are supplied to dressing-stations for
another purpose and should accordingly only be made use of in cases of grave
emergency. There is always plenty of lint and gauze, a stomach tube can be
improvised, and there are good rubber hot water bottles. Lastly, there is a set of
tracheotomy instruments of an up-to-date pattern. It will thus be evident at
once that from the anaesthetist's point of view the equipment of a field ambulance
leaves nothing to be desired. It may be added that all the materials supplied
are of admirable quality.

The cases which may require the administration of an anaesthetic before being
evacuated to a casualty clearing station may be divided into three main classes:^

(1) Cases where it is desirable to dress or redress a severe wound of an
extensive nature or to immobilize a fracture.

(2) Cases where it is considered necessary to perform an immediate operation
for the relief of some urgent symptom.

(3) Cases of wounds or injuries accompanied by shell-shock of an acute
maniacal type.

In the first group of cases are included severe shell injuries which can only be
thoroughly investigated when the patient is under an anaesthetic owing to the
extent and situation of the wound. The cleansing and dressing of many cases of
this type cannot possibly be carried out properly without anaesthesia, yet adequate

Clinical and other Notes 77

disinfection of a wound at an early moment may mean all the difference between
recovery and death from septicaemia. Again, something more than the first-aid
treatment of fractures is necessary in order to secure the comfort of patients who
may subsequently have to make a journey of several miles in a motor-ambulance
over bad roads. In these cases the value of anyesthesia in facilitating investiga-
tion and treatment is at once apparent. The administration of ether or chloro-
form is usually necessary in cases of severe burns, owing to the extreme pain
which dressing of the parts entails.

It must be clearly understood that many of the cases in this first group would,
in time of great stress and urgency, be evacuated from the dressing station almost
immediately. It is at normal periods that the conditions are most suitable for
the exercise of the methods outlined above. There are undoubtedly many
advantages in dealing as effectively as possible with patients in field ambulances
when the opportunity presents itself.

The majority of these cases offer the anaesthetist little difficulty. There are,
however, certain complications which are always likely to be met with when a
patient is anaesthetized within a short distance of the line. They may be briefly
summarized as follows: (1) Shock; (2) haemorrhage; (3) vomiting; cardiac
collapse.

Shock is usually present in a greater or less degree in cases of extensive and
destructive injury to the tissues, even when the part involved is in a relatively
insensitive area. Haemorrhage is of less common occurrence, the torsion of the
vessels which usually takes place in the severe laceration resulting from large
shell wounds effectually preventing much loss of blood. Occasionally severe
venous bleeding has occurred before the patient's arrival at the dressing station,
and he may then exhibit definite symptoms of collapse which call for the exercise
of special care. An attempt should always be made to differentiate between
collapse due to shock and that resulting from haemorrhage, since treatment by
intravenous saline, of the utmost value in some cases of haemorrhage, would now
appear to be contra-indicated in conditions of shock. ^

Vomiting is of frequent occurrence and is often very troublesome. The
explanation of its frequency is to be found in the fact that the patient has almost
certainly been given a quanity of stimulating fluid to drink after being hit, either
at the aid-post or on arrival in the field ambulance. Interrogation of a patient
will often elicit the information that two or three cups of hot soup or coffee have
been taken during the journey down from the trenches, with the result that the
stomach is distended with fluid at the time of operation. It is well to bear this
fact in mind and to remember that an empty stomach is the exception rather than
the rule. In cases where a man has been wounded immediately after a heavy
meal and has been brought in for operation a stomach tube should be passed and
the gastric contents removed.

Symptoms of cardiac failure are not common in this class of case, but this
possibility must always be guarded against in view of the fact that the patient
has almost invariably been treated with an injection of morphia before coming
under the anaesthetist's hands. It frequently happens that more than one injec-

''• Surgical Shock and some Allied Conditions" (Medical Research Committee), .Bn7is/i
Medical Journal, March 24, 1917.

78 Clinical and other Notes

tion has been given, and I have seen cases where misguided energy in this
direction has nearly led to the patient's undoing. A severely wounded man who
has been given an excessive amount of morphia before being brought in is scarcely
in a fit condition for the administration of an anaesthetic even under the most
favourable circumstances. The greatest care is necessary in dealing with cases
which have been overdosed in this way, circulatory failure occurring very
frequently even under ether.

For the dressing of w^ounds and the immobilization of fractures anaesthesia
may be conveniently induced with the A.C. mixture (alcohol one part, chloroform
nine parts), and maintained with open ether or the original agent. Ether should
not be used extravagantly or unnecessarily, for it is now an expensive commodity.
It is, however, readily obtainable from tne advanced depot of medical stores.
The A.C. mixture is usually very well borne. It should be administered from a
drop-bottle and should invariably be given by the open method on a folded square
of lint held well away from the patient's face. Given under these conditions it
forms an admirably safe and effective agent. Little muscular relaxation can,
however, be produced at an early stage of anaesthesia, and the more complete
degrees necessary foi the manipulation of fractures are more readily obtained by
the use of ether. The widespread habit of cigarette smoking is responsible for a
great deal of chronic pharyngeal irritation, which is met with very frequently
among patients of all ranks, and unless atropine ^ho grain is given as a routine
practice before the commencement of etherization considerable difficulty may be
experienced from the accumulation of mucus in the throat. Ether should be
given by the open method, the mask being covered with eight thicknesses of gauze.
A narrow ribbon of gauze may be interposed between the side of the bottle and
the cork in order to maintain a continuous flow, a bottle with a perforated cork
and two-way tube not being available.

Formal surgical operations are occasionally undertaken in field ambulances,
immediate operative treatment affording the patient the only chance of recovery.
The majority of such cases are of an exceedingly grave type, amputations and
laparotomies being perhaps most common. These patients are naturally difficult
subjects for anaesthesia and need the greatest care and attention. Induction is
best carried out with a C.E. mixture (chloroform two parts, ether three parts)
given on folded lint by the open method, anaesthesia being subsequently
maintained with open ether and oxygen. I believe that pituitary extract is of
real value in these cases in maintaining the blood-pressure and tiding the patient
over a dangerous period. At the same time every effort should be made to
maintain the body temperature, and too much stress cannot be laid on the
necessity for keeping these cases under careful observation after they have been
removed from the operating table. They should be placed in the warmest avail-
able position, while an orderly should be placed in special charge of each patient
in order that he may be properly looked after and any change in his condition
reported at once. In the hurry and confusion of dealing rapidly with a large
number of patients these cases are apt to be neglected once the operation is over,
chiefly owing to the fact that the nursing staff do not sufficiently realize the
gravity of their condition. These operations, frequently undertaken under most
adverse circumstances and solely with the idea of giving the patient some slight
chance of recovery, are occasionally brilliantly successful, and the anaesthetist
should be prepared to take any risk which the decision to operate may involve.

Clinical and other Notes 79

Certain cases of shell-shock arrive at the dressing station in a state of excita-
bility bordering on acute mania. Very frequently such patients have some
w^ound or injury which needs to l)e treated, but owing to the violence of their
struggling it is often exceedingly difficult to deal with them. \ little chloroform
or C.E. administered very cautiously and gradually will save an infinite amount
of time and unpleasantness, while the wounds can be properly dressed, the
patient removed to a suitable spot, and due precautions taken before the return
of consciousness. Unless there is reason to suppose that an injection of morphia
has already been given, ^ grain may be administered, with an added small dose of
hyoscine at the conclusion of anaesthesia.

NOTES ON THE TEEATMENT OF AMCEBIC DYSENTERY
WITH EMETINE AND BISMUTH IODIDE.

By Captain A. C. LAMBEET.
Boyal Army Medical Coi^ps.

During the months of July and August, 1917, forty cases of amoebic dysentery
admitted to a military hospital in Mesopotamia were treated with emetine and
bismuth iodide, used either alone or in conjunction with emetine hydrochloride.

These cases formed twenty-five per cent in July and thirty-four per cent in
August of all cases admitted in which blood and mucus were present in the
stools. They also furnished all the severe cases and the deaths from dysentery
during the above period. Four deaths occurred, in two of which hyperpyrexia
from the intense heat undoubtedly hastened the end. The remaining two were
due to peritonitis following perforation of dysenteric ulcers, and occurred in very
debilitated subjects two or three days after admission.

The duration of the disease before admission to this hospital varied from three
days to a fortnight, the average being about six days. In many cases could be
elicited a history of previous attacks of dysentery in either Mesopotamia or India.

All patients treated were natives of India, and came from widely separated
districts of that country. As this was the first opportunity afforded the writer of
making a trial of emetin and bismuth iodide in a series of cases of amoebic
dysentery the diagnosis of which could be confirmed, and the results of treatment
checked by microscopical examination of the fresh stools, the following points
were considered worthy of investigation : —

(1) The tendency, or otherwise, of the drug to produce vomiting.

(2) Its action, either when given alone, or in conjunction with emetin
hydrochloride, in

(a) Acute cases showing active amoeboid forms in the stools ;

(b) Less acute cases in which encysting forms are appearing in the stools ;

(1) The action of the drug in producing vomiting had to be taken into
consideration, as keratin capsules were not available, and the drug had to be
administered in the form of a powder or pill. Happily it was found that the
Indian tolerates the drug very well. The maximum single dose of three grains
was never exceeded, and not more than four grains were given during the twenty-

80 Clinical and other Notes

four hours. The roost suitable dose was found to be one of two grains, in pill
form, given once or twice a day, half an hour after a feed of milk, the pills being
freshly made from the powder with a little gum excipient. A few of the cases
complained of nausea after taking the drug, and sometimes the patient would
vomit an hour or two later, but this was readily checked by the administration
half an hour before of 15 drops of tinct. opii ; tolerance was established in two
or three days, and in no case did it become necessary to discontinue the drug
from this cause.

(2) The cases divided themselves pretty definitely into the three classes given
above, so that the action of the drug can be considered in its relation to each
class.

Acute Cases.

In those cases in which the disease had been present three or four days, and
in which several stools containing mainly blood and mucus were passed during
the twenty-four hours, microscopical examination showed the presence of
numerous amoebae of histolytica type. In the treatment of this class, the best
results were obtained by using two grains of emetin and bismuth iodide in pill
form at night, and one grain of emetine hydrochloride hypodermically in the
morning. A more rapid relief of the acute symptoms was obtained by this
method than by the use of either drug alone ; in fact, emetin and bismuth iodide
when given alone in acute cases did not appear to have the same rapid action in
relieving pain and tenesmus as emetin, but when used in combination with the
latter drug in the above manner it certainly shortened the attack, and established
a more complete and earlier convalescence. The rapidity with which the stools
became faecal and lost their blood and mucus was in some cases remarkable.
Furthermore, there did not appear to be the same tendency to constipation,
which so frequently follows the. use of emetin alone.

The microscopical findings showed a rapid decline in the number of amoeboid
forms in the stools after twenty-four hours, and by the end of a week the stools
were reduced to one a day, were in appearance normal, and apparently free from
amoebae in any form.

Case 1. — Havildar major, admitted August 5, 1917, with symptoms of
dysentery. Had been in hospital a fortnight previously with diarrhoea, which
cleared up under salines. No amoebae found at that time in the stools. On
second admission he was passing five or six stools daily, consisting solely of
blood and mucus, and containing numerous amoebae of histolytica type. Emetine,
one grain hypodermically in the morning and emetine and bismuth iodide three
grains in pill at night, commencing on August 6. Shght nausea, but no vomiting
after taking pill. Toleration established after two days.. Ou August 10, dose of
emetine and bismuth iodide reduced to two grains. Blood and mucus absent
from stools on August 8, and pain and tenesmus disappeared. Stools one daily,
semi-solid, until August 14, when they became solid and free from amoebae.
Keturned to duty on August 17. Total emetine injected, twelve grains. Total
emetine and bismuth iodide given, twenty-eight grains.

Case 2. — Driver, admitted July 23, 1917, with severe acute dysentery of four
days' duration. Passing numerous stools containing much blood and mucus.
Active amoeboid forms of E. histolytica present. Treatment commenced on
July 24, with emetine one grain hypodermically in the morning, and emetine

Clinical and other Notes 81

and bismuth iodide three grains at night. Griping and tenesmus relieved
after twenty-four hours. Blood and mucus in diminishing quantities present
in stools up to August 1. One normal stool passed on August 3, which was
free from blood, .mucus and amoebae. Patient then transferred to another
hospital.

Subacute Cases in which Cysts were' Present.

In cases which had passed the acute stage when admitted, and whose
symptoms consisted of pain and tenderness along the course of the large bowel,
more marked over the caecum and lower part of descending colon and rectum,
and the passage daily of two or three semi-solid or liquid faecal stools containing
a little mucus and a trace of blood ; good results were obtained by giving two
grains of emetine and bismuth iodide in pill morning and evening, with an occa-
sional dose of 5 ounce of 'sulphate of soda. Mucus and blood disappeared rapidly
under this treatment, the tongue became clean, and the abdominal tenderness
diminished, while, so far as could be judged with the laboratory appliances at
disposal, cysts ceased to be found after five or six days of treatment. Treatment
was continued until a total of thirty-six to forty grains of emetin and bismuth
iodide had been taken. Diet consisted of milk, sago and rice pudding, chicken
soup and eggs.

Case 3. — Sepoy, admitted on August 18, 1917, complaining of diarrhoea, pain
and tenderness along the course of the large bowel and the passing of small
quantities of blood and mucus in the stools, of which he had two or three daily,
Duration of illness fifteen days. No history of previous attacks. Two and four-
nuclear cysts found in stools. After a preliminary dose of ol. ricini, treatment
was commenced on August 19 by giving two grains of emetine and bismuth
iodide morning and evening. Blood and mucus were absent on August 21, and
the stools were normal and apparently free from cysts on August 23.

Case 4. — Driver, admitted on August 16 1917, complaining of diarrhoea,
with the passage of small amounts of blood and mucus. Two to three stools daily.
Illness of about a fortnight's duration. No history of previous attacks. Cysts in
stool containing up to four nuclei. Emetine and bismuth iodide in two-grain
doses twice daily commenced on August 18. Stools normal and free from cysts
on August 21.

Chronic Eelapsing Cases.

Under this category are classed cases who had had one or more previous
attacks of dysentery from which they had never fully recovered. When admitted
to hospital they were very debilitated and anaemic. Usually of the " follower "
class, they had continued their duties long after they should have reported sick.
The stools passed, often sixteen to twenty in a day, consisted of blood, mucus and
sloughs, while not infrequently blood alone was passed, and in considerable
quantity. Great tenderness was complained of along the whole course of the
large bowel, and there was much griping and tenesmus. Emaciation was
extreme in some cases. These cases furnished all the four deaths occurring
during the period under review, and the post-mortems showed extensive ulceration
and gangrene of the whole of the large bowel from caecum to anus. The stools
contained numerous amoebae in all stages of development. Owing to the severity
of the symptoms it was necessary to get these patients as quickly as possible
under the influence of emetine, in order to destroy the amoeboid forms which were
6

82 Clinical and other Notes

doinc such harm to the already damaged coats of the bowel. Emetine hydro-
chloride, therefore, was given at first in doses of from a half to one grain, hypo-
dermically twice daily. Later on, as the symptoms improved, one or two grains
of emetine and bismuth iodide were substituted for one of thp doses of emetine.
Small doses of morphia were used to allay pain and tenesmus, and promote sleep.
Stimulants, such as brandy or port wine, had generally to be given, and in such
debilitated cases the diet had necessarily to be bland, nourishing, and readily
assimilable, and consisted of milk, milk and eggs, meat essences, milk puddings
and light soups. Convalescence in these cases was prolonged, and return to
normal dietary had to be carefully regulated.

Case 5. — Dhoolie-bearer D., admitted on August 6, 1917, with diarrhoea and
debility, and a history of several weeks of ill-health, abdominal pain and the
passing of mucus with the stools. He was passing from sixteen to twenty stools
daily, was very weak and emaciated, and could scarcely articulate. He had
continued on duty till forced by weakness to seek medical aid. Liver and spleen
not palpable. Temperature 99"^ to 100° F. Pulse very rapid and weak. Tongue
furred, dry, and protrilded with difficulty. Lungs showed poor air entry and signs
of old pleurisy. He was at first considered to be a case of phthisis, with
diarrhoea, but no tubercle bacilli could be detected in the sputum. Blood was
negative as regards malaria. Examination of stools showed, at first, no amoebae,
but on the 10th there was a little blood and mucus in the stool, and amoebae were
then found. He was at once put on emetine hypodermically, in doses of one
grain daily, and on the 13th, when the symptoms had improvei^, and his general
condition was better, two grains of emetine and bismuth iodide were given in the
evening to supplement the emetine. The former drug was well borne and caused
no vomiting. By the 16th there was slight improvement, but patient was still
very weak aud depressed and was passing five or six stools a day. On the 17th
he was much better, and there was no blood and mucus in the stools, and the
emetine was discontinued. On the 19th, the stools contained neither amoebae nor
cysts, but the emetine and bismuth iodide were now given in two-grain doses
twice daily. The appetite had returned, and the patient commenced to pick up.
Medicinal ti'eatment was stopped on September 1, after a total of nine grains of
emetine and forty grains of emetine and bismuth iodide had been given. A few
days later the patient was transferred convalescent to another hospital.

The above case is a very fair illustration of the action of emetine aud bismuth
iodide in severe amoebic dysentery in debilitated subjects.

No mention has been made of the use of enemata, and, in fact, very little use
was made of that method of treatment. In the milder cases it did not appear
called for, and in the severe type similar to the last described it seemed to be a
highly dangerous proceeding, considering the state of the bowel in these cases, as
illustrated post mortem. Appendicostomy or caecumostomy were not attempted,
as the cases were too debilitated to stand operative interference, and their
symptoms appeared to be relieved to a great extent by medication.

Judging by the results in this small series of cases, it would seem that we
have in emetine and bismuth iodide a combination of considerable potency in the
treatment of amoebic dysentery, particularly when the amoebee are assuming their
resistant stage. When given in pill form in doses not exceeding two grains, its
emetic effects are slight, at all events in Indian cases. Its use in conjunction

Clinical and other Notes 83

with hypodermic injections of emetine hydrochloride in acute amoebic dysentery
would seem to be beneficial, in that convalescence is established earlier and
patients are less likely to become " carriers." It cannot be considered in the
light of a substitute for emetine, as attempts to treat acute cases with it alone
ended in failure, until emetine was used in addition.

In "carriers" and in those convalescents who continue to harbour cysts,
emetine and bismuth iodide should prove superior to emetine, and it would seem
a wise proceeding, from a public health point of view, to subject all cases
of amoebic dysentery to a course of emetine and bismuth iodide during
convalescence.

I wish to express my grateful thanks to Colonel W. H. Willcox, C.B., A. M.S.,
consulting physician to the forces in Mesopotamia, for his kind and valuable
advice and help in the treatment of the cases, and the compilation of these notes.
And also to my indefatigable assistant, Sub-assistant Surgeon Bashi Earn, without
whose inteUigent aid and knowledge of the vernacular the cases could not have
been systematically treated or noted.

NOTES ON THE TREATMENT OF SUBTERTIAN CEREBRAL

MALARIA WITH QUININE AND GALYL.

By Major A. W. FALCONER.

Boyal Army Medical Corps.

AND

Captain A. G. ANDERSON.
Boyal Army Medical Corps.

Salvarsan and neosalvarsan have been used to a considerable extent during
the last six or seven years in the treatment of malaria. Most observers are
agreed that these drugs, especially when associated with quinine, are of value in
infections with the benign tertian and quartan parasites, but are of little value
against infections with the Plasviodium laveranicB. Although quinine alone may
justly be termed a specific in the treatment of most types of malaria, the death-
rate from malignant subtertian malaria is yet suflQciently high to stimulate further
effort to find an even more efficient therapy.

The following six cases were' treated with a combination of quinine and
galyl :—

Case 1. — Pte. C, aged 31, admitted to base hospital on September 22, 1916.
He had reported sick on September 18, complaining of headache, vomiting, and
" the shivers." He stated that for the previous three months he had been having
attacks of shivering and sweating at irregular intervals. On admission to
hospital his general condition was good, his temperature was normal, and his
spleen extended half an inch below his costal margin. He was treated with
twenty grains of quinine sulphate three times a day by mouth. He felt quite
well and his temperature remained normal until the morning of September 25.
On that date his temperature rose to 100*^ F. and remained up all day. On the
morning of the 26th it had fallen to normal, but rose again in the evening to
101^ F., and the patient felt sick and vomited. An injection of twenty grains
quinine bihydrochloride was administered intramuscularly. On the morning of the

84 Clinical and other Notes

27th another injection of twenty grains of quinine was given intramuscularly.
His temperature was normal, and did not rise above normal throughout the day.
At noon the patient refused his food, and looked strange ; at 3 p.m. he was
found to have complete paralysis of the muscles of both sides of the tongue, of
the pterygoids and of the masseters. There also appeared to be some weakness
of the external recti. There was no paralysis of the limbs, or alteration of the
superficial or deep reflexes. The patient was quite conscious and could carry out
directions as to the movements of his limbs ; the fundi oculorum were normal.
A blood-film showed the presence of numerous subtertian rings and crescents.
He was given an intravenous injection of 0-8 gramme quinine bihydrochloride.
At 8 p.m. the patient's condition was unchanged, except that he now appeared to
have some difficulty in understanding what was said to him. There was a definite
internal strabismus of the left eye ; a further 0-8 gramme quinine was ad-
ministered intravenously. On the morning of the 28th his condition was much
improved. He could open his mouth, protrude his tongue, and articulate slowly.
He had some difficulty in swallowing, as fluids tended to regurgitate through the
nose. There was still defective movement of both eyes outwards. In the after-
noon his temperature rose to 100° F. On this date he was given two intravenous
injections of quinine bihydrochloride 08 gramme each. On the morning of the
29th his condition was much worse. There was complete paralysis of the tongue,
the palate, and the muscles of mastication. There was also complete ophthalmo-
plegia, and it was doubtful whether the patient understood what was said to him.
At 9 a.m. he received a further 0-8 gramme quinine bihydrochloride intravenously.
At 11 a.m., as there was no improvement in his condition, he was given
0-3 gramme galyl intravenously. At 3 p.m. the patient was much improved. He
could then protrude his tongue, move his jaw, talk slowly but quite intelligently",
swallow slowly, and move his eyes. At 9 p.m. he was given a further 0 8 gramme
quinine intravenously. On the 30th the patient's condition had continued to
improve. There was still some dysarthria, but he was able to swallow without
difficulty. He was put on 20 grains of quinine sulphate three times a day by
mouth. The improvement steadily continued, but on October 1, as the tempera-
ture still rose to 100" F., he was given 0-2 gramme galyl intravenously. The
temperature fell that night and remained subnormal during the rest of his stay in
hospital. He showed no further symptoms and was transferred to hospital ship
on October 18, when there was no evidence of organic nervous disease, and no
malarial parasites could be found in the blood.

Case 2. — Sapper E., aged 33, admitted to base hospital on October 4, 1916.
On admission the patient's general condition was bad, and the temperature was
103° F. He showed no evidence of any local lesion of the nervous system. A
blood-film showed the presence of numerous subtertian malarial parasites. He
was given 0-8 gramme quinine bihydrochloride intravenously. On the morning
of the 5th his temperature was subnormal, but his general condition was very
poor. He was again given 08 gramme quinine intravenously, and at 2 p.m.
twenty grains of quinine sulphate by mouth. In the afternoon the patient
developed marked dysarthria and difficulty in swallowing. The speech was
quite uuinteUigible. The movements of the tongue and palate were present
but much impaired. The patient's mental condition was not affected, and
there was no paralysis of the limbs or alteration in the superficial or deep

Clinical and other Notes 85

reflexes. At G p.m. he received 0-4 gramme of galyl intravenously. On
the 6th the patient's general condition was much improved, and beyond
slight dysarthria, which rapidly passed off, he showed no evidence of local
disease of the nervous system. He was then treated with quinine intra-
muscularly, and later by mouth, and rapidly became convalescent. He was
transferred to hospital ship on October 21, without any evidence of organic
nervous disease.

Case 3. — Pte. B., aged 48, admitted to base hospital on the night of October 7,
complaining of headache and general weakness. On admission his temperature
was 103° F., but fell to 99° F. on the morning of October 8. His general con-
dition was fair, and his spleen extended about one inch below the costal margin.
He was treated with twenty grains of quinine sulphate three times a day by
mouth. He took his dinner at noon on the 8th without discomfort, but at 4 p.m.
it was found that he was unable to swallow his tea, and he rapidly became
unconscious. A blood-film showed the presence of numerous subtertian rings
and crescents. When seen at 5 p.m. he was lying in a semi-conscious condition,
and did not pay any attention to what was said to him. The conjunctival reflex
was present and the superficial and deep reflexes were normal. The uncon-
sciousness rapidly deepened, and he could not be roused by any stimulation.
He received 08 gramme of quinine bihydrochloride at 5 p.m., 7 p.m., and 10p.m.
At 11 p.m. his condition was unchanged, except that his pulse was failing. He
then received 0-4 gramme of galyl intravenously. "When seen at 6 a.m. next
morning he was quite conscious, able to answer questions slowly and intel-
ligently, and swallow. His temperature was subnormal, and remained so for the
remainder of his stay in hospital. A blood-film showed the presence of scanty
subtertian crescents up to October 15, but he showed no further symptoms and
was transferred to hospital ship on the 22nd.

Case 4. — Pte. C, aged 26, admitted to the base hospital on October 10. On
admission the patient's general condition was poor, his temperature was 99° F.
and his spleen extended about one inch below his costal margin. A blood-film
showed the presence of rings and crescents. He tended to be drowsy, but
answered questions quite intelligently, and had no complaints. He was given
0-8 gramme quinine bihydrochloride intravenously. On the morning of the 11th
the patient's general condition was worse, he was more drowsy, and answered
questions with difliculty. The pulse was 120 per minute and feeble. He received
fifteen grains of quinine bihydrochloride intramuscularly. At 3.30 p.m. his con-
dition suddenly became much worse ; his breathing became stertorous, and his
pulse imperceptible ; he lay moaning incessantly, and rolling his head from side
to side. There was no paralysis, and his superficial and deep reflexes were
normal. His temperature was subnormal. At 4 p.m. he became violent, and lay
on his left side in the typical attitude of cerebral irritation. He violently
resisted any interference with this position. He received 0-4 gramme galyl
intravenously. At 9 p.m. the patient's condition had definitely improved. He
had slept for two hours and his pulse was better. At 1 a.m. on the 12th he
again became rather excited, and was given j-i^ grain hyoscine. After this he
slept, and when he woke was rational, though weak. From this date he rapidly
and steadily improved, and on the 22nd was transferred to hospital ship without
presenting any further local symptoms.

86 Clinical and other Notes

Case 5.— Pte. L., aged 20, admitted to the base hospital on October 15, 1916,
with a diagnosis of malaria. On admission his temperature was normal and he
presented no local symptoms. His spleen extended half an inch below the costal
margin. He had never suffered from fits nor had any of his family done so. On
October 16, whilst in the latrine, he suddenly developed an epileptiform fit.
After having been brought back to the ward, he was in a very confused condition,
and paid no attention to any questions, but constantly attempted to get out of
bed. The blood-film did not show any malarial parasites. His temperature had
risen to 101-4° F. During the 16th he continued to have epileptiform fits, and in
the twenty-four hours had some twelve in all. The clonic convulsions were
general and did not appear to begin constantly in any particular part, but they
were always associated with marked deviation of the head and eyes to the left.
Between the fits he was either extremely drowsy or violently delirious. At 2 p.m.
he received 0-8 gramme quinine bihydrochloride intravenously, and at 6 p.m.
twenty grains intramuscularly. On the morning of the 17th his temperature was
101° F. and his pulse-rate 80 per minute. He was very drowsy and had passed
no urine. He received twenty grains quinine intramuscularly. At 9 p.m. he
developed another fit, and it was noted that the left plantar reflex was extensor ;
the right plantar reflex was flexor. He was given 04 gramme galyl intravenously,
and a lumbar puncture was performed. The cerebrospinal fluid appeared to be
under increased pressure, and two testtubefuls of clear fluid were drawn off.
The cerebrospinal fluid showed no increase in cellular elements. At 8 p.m., as he
had passed no urine for thirty-six hours, a catheter was passed, and less than an
ounce of urine was obtained. It did not contain any albumin, sugar, or casts.
On the morning of the 18th the temperature was normal, and the patient's general
condition improved. He answered questions quite readily and was taking his
nourishment well. The left plantar reflex was still extensor, and there were
marked nystagmoid jerkings of the eyes on lateral movement to either side.
The left leg was distinctly weaker than the right, but was capable of performing
all movements with a fair amount of force, and there did not appear to be any
ataxia of the limbs. Urine was being passed quite freely. He was given two
doses of twenty grains quinine intramuscularly on this date. From this date
onwai-ds he was treated with quinine, at first intramuscularly, and later on by
mouth. Convalescence was uninterrupted. The weakness of the left leg rapidly
improved, but the plantar reflex remained extensor for four weeks. The
nystagmoid jerkings of the eyes varied somewhat from time- to time, but
were still definitely present six weeks after the patient's admission to
hospital. When able to get up he showed a pronounced reeling gait, and
unless supported he tended to fall to the left. He stated that he felt as if
his head were being pulled to the left. When made to walk holding his head
down to his right shoulder with his right hand, the tendency to reel to the left
was diminished, but was still present. There was no Eombergism and no ataxia.
The optic disks were normal. He had no further fits after the 18th, and was
transferred to hospital ship in February, 1917.

Case 6.— Dr. S., aged 22, admitted to hospital on September 29, 1916. He
reported sick on the 21st, complaining of pain in the head and back, and diarrhoea.
On admission to hospital, his general condition was fair, his temperature 103° F.,
his pulse 120 per minute, and his spleen two inches below the costal margin.

Clinical and other Notes 87

He was put on forty'grains of quinine sulphate by mouth per day. On October 2,
as the temperature wa§ still raised he was given twenty grains of quinine
bihydrochloride intramuscularly in addition. On the 4th his temperature did not
rise above 99'' F., and he appeared somewhat better. On the 5th the tempei^ature
again rose to 101-4° F., and he complained of some pain in the neck and a little
difticulty in swallowing. No definite affection of the cranial nerves could be
made out, but the right plantar reflex was definitely extensor. He was again put
on quinine intramuscularly. On the 6th the temperature again rose ; he still
complained of pain in the neck, and the right plantar reflex was still extensor.
The respirations had increased in frequency, and there was some dullness at the
base of the right lung posteriorly. He was given two doses of 0-8 gramme
quinine intravenously. On the 7th, as there was no improvement, he was
given 0-4 gramme galyl intravenously. He died on the morning of the 8th.

Post-mortem. — The whole of the upper and lower lobes of the right lung were
solid in a condition of grey hepatization. There was a considerable accumulation
of cerebrospinal fluid below the tentorium and some oedema of the pia-arachnoid
over the pons and medulla. The brain was hardened in formalin and then
sectioned, but it did not show any macroscopic change.

In these six cases galyl was used in association with large doses of quinine.
So fat we have been able to make only a limited number of observations of the
effect of galyl alone on the subtertian parasites in the peripheral blood-stream,
but that galyl alone can cause the disappearance of the ring forms of parasite
from the peripheral blood-stream is shown by the two following cases.

Case 7. — Sister S., aged 28, admitted to hospital on November 12, 1916, with
pyrexia. Numerous subtertian rings were present in the blood. The patient
was put on twenty grains quinine sulphate three times a day by mouth. This
produced constant vomiting, headache, and very troublesome tinnitus aurium.
The parasites persisted in the blood-stream and the pyrexia continued. On
November 14 she was put on intramuscular injections of quinine bihydrochloride,
twenty grains twice a day. The intramuscular injections were continued for four
days, but the patient was extremely intolerant of quinine and complained of
violent headache, and tinnitus aurium with occasional vomiting. The temperature
was swinging between 97° and 101'' F. Subtertian rings were constantly present
in considerable numbers in the blood. She was again put on quinine by mouth,
but, on account of vomiting, it was impossible to get her to take it regularly.
An intermittent pyrexia continued up to November 27, and during this period
subtertian rings wei'e constantly present in the blood. On November 27 she
received 0*2 gramme galyl intravenously. Her general condition definitely
improved, but the blood still showed subtertian rings, although in diminished
numbers, up to December 6, when she had a second dose of 0'4 gramme galyl.
From this date onwards there was a marked general improvement in her condition,
although she still continued to show an irregular pyrexia rising to 100° F. at
night ; her blood was examined every few days for malarial parasites until
her discharge some two months later, but these were not again found. On
December 10 typhoid bacilli were isolated from the stools, and on January 2, 1917,
she developed a periostitis of the right humerus.

Case 8. — Pte. B., aged 26, elsewhere reported in detail, was admitted to
hospital on the night of October 4, 1916. On October 5 his temperature rose

88 Clinical and other Notes

to 102° F. ; his general condition was poor, his sclerotics icteric, and he presented
gangrene of the toes of both feet. A blood-film showed the presence of rings
and crescents, anisocytosis, poikilocytosis, and polychromatophilia. As it was
considered possible that a vascular spasm aggravated by quinine might play a
part in the condition of the feet, he was not put on quinine but given 0-3 gramme
galyl intravenously. His temperature fell that night and remained subnormal
throughout the rest of his stay in hospital. His general condition rapidly
improved, and a blood-film taken on the LOth was reported negative to malarial
parasites. Two other blood-films taken later were also reported negative. Before
his discharge to hospital ship he was put on ten grains of quinine sulphate twice
a day by mouth.

In this case it will be noted that the crescents also disappeared rapidly from
the blood, but in most of our cases of combined quinine and galyl treatment the
crescents have been much more persistent, as in the following case.

Case 9. — Pte. K., aged 25, admitted to hospital on December 23, 1916, with a
diagnosis of bronchitis. The patient had been in hospital in May, 1916, with
a diagnosis of P.U.O., and in October with malaria. He had not felt well since
leaving hospital in October, and he stated that he had had frequent shivering fits
since then. During September and October he had taken thirty grains quinine
by mouth per day, but had only been taking it irregularly in November and
December. On admission his general condition was poor. His temperature
was 102° F. and rose to 103° F. next day, to fall to normal on the 25th, His blood
showed numerous subtertiau crescents and rings. From December 24 to 27 the
number of crescents met with in counting 200 leucocytes was practically constant,
the figures being 100 crescents to 200 leucocytes. On the 27th he was giveb
0-4 gramme galyl intravenously. On the 29th the crescents had fallen to 50,
on the 30th to 36, for every 200 leucocytes. On the 30th he again received
0-4 gramme galyl. On December 2 the crescents had fallen to 24 in 200 leuco-
cytes, on the 8rd to 14, and on the 4th to 7 crescents for every 200 leucocytes.
On the evening of the 11th he developed catarrhal symptoms with a temperature
of 101° F., but without any rigor. A similar condition was at that time present in
the ward and was almost certainly not malarial. The temperature was normal
on the 6th, and on the 6th and 7th the crescents numbered respectively 11 and 10
to 200 leucocytes. He received another 0*4 gramme galyl on the 7th. On the
8th his temperature rose again and he had a malarial attack. Eings were found
in the blood on the 9th. His temperature became normal again on the 11th and
his blood showed no rings, but 23 crescents to 200 leucocytes. He was put on
forty grains quinine bihydrochloride intramuscularly once a day, and twenty
grains quinine sulphate twice a day by mouth. On the 13th, 14th and 15th his
blood showed 8, 7 and 8 crescents respectively to 200 leucocytes. On the 23rd
and 24th 1 crescent to 200 leucocytes was found, and on the 25th and 26th no
crescents could be found in counting 300 leucocytes. On February 1, 1 crescent
was found in counting 200 leucocytes, on the 2nd, 3 crescents to 200 leucocytes.
On the 4th and 6th no crescents were found in counting 400 and 300 leucocytes
respectively. His general condition was now excellent and he was transferred io
hospital ship on February 7th.

With regard to the value of combining galyl with quinine in serious cases
of malaria, our experience is yet too limited to permit of any dogmatic statements

Clinical and other Notes 89

as to its eflicacy. It will be noted that, in the first six cases reported here,
all were seriously ill with definite subtertian cerebral malaria. All the cases
recovered, with the exception of one who died of a complicating croupous
pneumonia. All had received quinine, several of them large doses by mouth,
intramuscularly, and intravenously, without clinical improvement. In all of
them, with the exception of the fatal case, the clinical improvement after the
administration of galyl was striking and immediate. In none of the cases did
the injection produce any unpleasant results, although several of the cases
appeared almost moribund before the injection.

In the eighth case, in w^hich it was considered inadvisable to give quinine,
galyl aloue caused the disappearance of the parasite from the peripheral blood
and produced a striking improvement in the condition of the patient.

In Case 7 the patient took quinine in any form with great difficulty, and
although she had taken a considerable amount of quinine by the mouth and
intramuscularly, ring forms of the subtertian parasite were constantly present in
the blood. After the first half-dose of galyl there was a notable clinical improve-
ment, but the parasite could still be demonstrated in the blood. After the second
dose the parasites at once disappeared from the blood. The typhoid ran a
protracted course, and she developed a periostitis of the left humerus, but in spite
of repeated examinations parasites were not again demonstrated in the blood
during the rest of her stay in hospital.

In Case 9, subtertian crescents were present in large numbers. Under
treatment by galyl alone they diminished from 100 per 200 leucocytes to seven
or eight. The patient's general condition very greatly improved, but he still
developed a malarial attack with the presence of rings in the blood. These
rings disappeared under treatment by intramuscular quinine, and the crescents
continued to diminish and were absent on February 7, when he was transferred to
a hospital ship.

We consider that we are justified in concluding : —

(1) That the treatment in itself is free from danger.

(2) That, in subtertian malaria which is resisting adequate quinine treatment,
or where the condition is sufficiently alarming, the results of the combined galyl
and quinine treatment have been encouraging enough to justify a further trial.
It must be thoroughly understood, however, that the addition of galyl in no way
diminishes the necessity for quinine.

(3) That in cases where, on account of idiosyncrasy, quinine is impossible,
a valuable substitute may be found in galyl.

We take this opportunity of thanking Colonel Purves Stewart, C.B., A. M.S.,
consulting physician to the Salonika Force, for his valuable assistance and advice,
which was always at our disposal. To Lieut.-Colonel P. Mitchell, E.A.M.C, T.F.,
we are also indebted for permission to use the hospital records, and to Captain R.
Eichards, R.A.M.C, T.F., for the haematological and post-mortem reports.

Clinical and other Notes

CEEEBROSPINAL FEVER : NOTES ON 251 CASES TREATED AT THE
SALISBURY ISOLATION HOSPITAL.

By J. E, GOEDON, M.E.C.S., L.R.C.P.

Hon. Pliijsician SaUsburi/ Infirmary; Medical Officer in Charge of Salishury and

District Joint Isolation Hospital.

The following brief notes relate to cases of cerebrospinal fever which have
occurred in Salisbury and the surrounding district and in some neighbouring
military camps, from December 15, 1914, to June 30, 1917.

The first case was admitted to the Salisbury Infirmary on December 15, 1911,
and from that date until February 23, 1915, 36 cases were admitted ; of this
number, 16 died in the Infirmary, 3 recovered and were sent back to their homes,
and the remaining 17 were transferred to the Salisbury and District Joint
Isolation Hospital on account of the impossibility of treating the increasing
numbers of cases in award of a General Hospital. Five of these 17 subsequently
died at the'Isolation Hospital. The total number of cases, both military and civil
(including the 17 mentioned above), admitted from February 23, 1915, to the
Isolation Hospital, was 232, making the total number of cases admitted into both
hospitals 251.

The following table gives separately the number of military and civil cases,
the recoveries and the deaths at all ages and at certain age groups, and the
percentage of the fatal cases to the total number of cases in each age group : —

Military.

Xuniber of cases at certain
age groups

Total number at all ages. .

Number iinder 20 j-ears of age

,, 20 to 25 ..

„ 25 to 30 . .

„ 30 to 40 ..
Over 40

Total number at all ages
Under 1 year of age

1 to 5 years

5 to 10 , ,
10 to 15 ,,
15 to 25 „ ..
25 to 45 ,,
45 to 65 ,,
Over 65 „

Xunil)er of
cases

Number of
reccn-eries

Xnmber of
deaths

Percentage of

deaths to

cases

155

101

34-8

426

27-3

.38-1

35-3

25-0

Civilian.

58-3

62-5\
76-2 ,

. 57-1 M

80-0

36-8^ ^
41-2, '

83-3 1

—

. 100-0 r ^

69-

38-9

85-7

From the table above it will be seen that the fatality rate of the military cases,
34-8 per cent, is lower than the corresponding rate for civil cases, 583 per cent.
The higher fatality rate at all- ages among the civilians may in some measure be
attributed to the comparatively large proportion of fulminant cases which
occurred in the cases in the 1914 to 1915 epidemic period; but in the main it is
due to the fact that many of the cases were infants and young children. It will
be seen that 53 (or 55-2 per cent) of the civilian cases are under 15 years of age,
having a fatality rate of 69-8. Among persons past middle life the mortality rate
was also high (85-7 per cent).

When the thirty-six (37-5 per cent) civil cases in the age groups 15 to 45, which
most closely correspond to the all-ages group of the military cases are examined,

Clinical and other Notes 91

it will be seen that the fatality rate of the civil cases is 38-9 per cent, and that of
the military cases 34-8 per cent. Although the civil fatality rate is four per cent
higher than in the military cases, the rates are calculated on small figures, and
too much reliance cannot be placed on them.

Of the 251 cases dealt with, there were 47 fulminant cases, 163 severe cases,
and 41 mild cases.

The length of illness of 110 fatal cases was as follows : —

Period of illness Civil cases Military cases

Less than one week . . . .* 24 . . . . 25

One to two weeks . . . . 5 . . . . 4

Two to four weeks .. .. '8 .. .. 12

Over four weeks. . .. .. 19 .. .. 13

56 54

The longest duration of illness before death was 129 and 131 days respectively
in civil and military cases.

In the civilian cases there were 56 males, and of these 21 recovered and 35
(or 62-5 per cent) died; and 40 females, 19 of whom recovered and 21 (or 52-5
per cent) died.

The civilian cases, with few exceptions, occurred amongst the working classes,
and except in three cases there was a definite history of association with soldiers
or camp workmen, or of residence in camp areas.

Civilian patients within a radius of twenty-five miles were conveyed to the
hospital by motor ambulance, and even the most severe cases seemed to stand the
journey well.

The ambulance used was a 20-h.p. Scout, body of wood, panels with glass
windows, interior varnished wood, all washable. The patient was kept warm with
hot-water bottles and blankets.

Age Distribution. — The disease may occur at any age, among the cases treated
at Salisbury the youngest was 3i months, and the oldest aged 72 years.

Clinical SviiPTOMS and Signs.
In all cases headache was present, usually of a severe type, and there was
pain and stiffness on moving the head in varying degrees according to the severity
of the case. In two very severe cases there was no stiff neck on admission, but
in twenty-four hours this sign was pronounced, Difficulty in swallowing, due to
extreme retraction of the head, was present in a few cases. Vomiting, sometimes
associated with diarrhoea, was present in 162 cases on admission, and had
probably been present in some of the cases admitted unconscious, in regard to
which no history of the illness was obtainable. Kernig's sign was present in
199 cases. Twenty cases had herpes on the face on admission. Many cases had
rashes on admission, the eruption being of various types, papular, haemorrhagic,
and purpuric spots being most common ; two cases had petechial rashes on the
joints. Broncho-pneumonia was present in fifteen cases. Bronchial symptoms
of a catarrhal type, probably meningococcal in character, occurred in some cases ;
these were usually of a temporary transient character, lasting only a few days, and
did not seem to influence the course of the disease. Convulsions occurred in
seven cases at the commencement of the illness ; three of these cases were under
1 year of age ; of the remaining four, one was 3| years, one 7^ years, one 18
years, and one 26 years of age. With three patients convulsions occurred at a
late stage of the disease, only one of these recovered. Retention of urine (m

92 Clinical and other Notes

frequently observed in female cases) did not indicate a bad prognosis when
occurring at an early stage of the illness ; it also occurred as a late development
in hopeless cases. One hundred and tv^enty-nine cases, v^hen admitted, were
more or less unconscious with delirium, frequently violent and maniacal. Some
cases were quite comatose. Haematuria was present in four military cases of
severe type, two of which were fatal. The other two made a complete recovery.
Albuminuria occurred in 11 cases — 10 military and 1 civilian — 3 of these cases
died. Of the recovery cases, one only had albuminuria on leaving the hospital.
Strabismus when present generally occurred in infants. A child, aged 5, who
recovered, had ptosis of the right eyelid on admission. At least four patients
recovered with blindness of one eye, caused by panophthalmitis, and in two cases
the eye was subsequently removed. Nystagmus occurred in one case as a com-
plication and sequela, the patient when discharged being otherwise in good health.
In three cases orchitis occurred as a complication during convalescence. Total
deafness occurred as a sequela in three cases in which recovery was otherwise
good. One patient, a male, aged 29, who died after five days' illness, had hemi-
plegia on admission. Another male, aged 18, had facial paralysis, but recovered
with no paralysis. Hydrocephalus was occasionally seen amongst the children
affected.

The Type of the Disease.

Acute Fulviinayit Type. — Duration of illness from a few hours to five or six
days. These cases were usually comatose or semi-comatose on admission with
h^emorrhagic rash and incontinence ; they were often delirious and troublesome
and did not recover consciousness.

Severe Tijpe. — These cases present several varieties ; on admission, some did
not appear to be very severe, but became so and ended fatally in two or three
weeks ; others became chronic, the course of the disease lasting sometimes
several weeks before death occurred. The latter patients became very emaciated
with mental degeneration and incontinence. The rapid recovery of some patients
admitted with delirium and high temperature and apparently suffering with a
most severe form of the disease, was remarkable. As a rule in severe cases
which recovered improvement began in less than two weeks, although it is
worthy of note that certain severe cases began to recover after a long period.

Mild Types. — These cases had headache, stiff neck, and generally vomiting ;
were sensible on admission, and Kernig's sign was present. Convalescence
commenced a few days after admission. Cultures from cerebrospinal fluid or
throat swabs were positive. The cerebrospinal fluid in these cases was generally
excessive in amount, either clear or faintly turbid (cloudy).

Chronic cases became emaciated; those ending fatally usually developed tremor
of the hands, sometimes purpuric or petechial rashes, loss of memory and incon-
tinence, and usually took nourishment well. Mental derangement in a chronic
case, associated with wasting, tremor, and incontinence, indicate, I consider, a
fatal termination; in fact I have only seen one case with these signs recover. On
the other hand, I have had recoveries of cases with emaciation, in which the
mental capacity has remained good, and after the acute stage the patients have
not had incontinence. Three patients were admitted with swollen joints and
myocarditis, their condition before admission suggesting acute rheumatism. In
these cases meningococci were found in films made direct from cerebrospinal
fluid, which in all these cases was turbid and excessive in amount ; two of these^

Clinical and other Notes 03

cases recovered, the cardiac signs and swelling of the joints disappearing during
convalescence. Arthritis affecting the knee or ankle joints occurred in seven
patients as a complication or sequela, two of these being fatal cases. The
temperature does not appear to take any definite or typical course. Cases with
some of the highest temperatures recorded recovered, and in some severe cases
of the fulminant type, where the illness ended fatally in a few days, the tempera-
ture did not rise above 100' F., or remained normal.

Diagnosis. — For correct diagnosis, lumbar puncture is essential. The cerebro-
spinal fluid of the first forty-five cases was examined and reported as positive by
Dr. Penfold, of the Lister Institute. Of the remaining cases the fluid of 1G3
was more or less turbid and diplococci were found in films made from the fluid
withdrawn, although in some of these cases no growth was obtained from
cultures on trypsin agar or blood serum (about 15| per cent). In two cases the
fluid was blood stained, and in one of these diplococci were found and a positive
growth was obtained ; in the other case no growth resulted, but a throat swab
furnished a positive growth. In forty-one cases the cerebrospinal fluid was clear
and excessive in amount. In these cases the albumin was generally increased,
and in some eight of them a positive growth was obtained by culture. In the
other clear fluid cases, the diagnosis was confirmed by subsequent punctures and
a positive throat swab was obtained.

The amount of fluid withdrawn varied, the average being from thirty to fifty
cubic centimetres. In some cases the fluid was in quantity and under consider-
able pressure, as much as eighty or 100 cubic centimetres escaping at times
through the needle. The cells found in the fluid were chiefly of the poly-
morphonuclear variety, the diplococci being both extra- and intra-cellular. I have
not found the position of the cocci, as regards the cells, to afford any assistance
in prognosis. One. patient, a male, recovered with nephritis as an after effect ;
four cases (already mentioned) with impaired vision. In the majority of cases
which recovered health has not been completely restored for some months ; in
others the recovery appeared to be fairly good, many patients having resumed
their occupations. The average period in hospital of recovery cases was: civilian
cases forty-five days, military cases sixty-six days. Since the opening of a
military carrier centre at Sutton-Veny and the transference to this centre of
military cases on convalescence, the duration of the stay in hospital of military
cases has been reduced, as in 1915 and 1916 military patients were retained in
hospital until two successive negative throat swabs were obtained.

Treatment. — I do not think that drugs have any specific action. In the
earlier cases (1915), in addition to lumbar punctures and serum, many drugs
were tried, soamin, urotropine, neosalvarsan, and potassium iodide, without
apparently any decided influence on the course of the disease in various cases,
and their use has been discontinued. For the relief of headache and sleepless-
ness morphia, morphia and atropin, heroin, bromide and chloral, were successful;
aspirin was very beneficial in the milder cases. In the severe forms, morphia
and heroin were given freely with satisfactory results. Saline solution given per
rectum or intravenously, always did good. Brandy was necessary in many
cases. Pituitary extract and ether were found preferable to strychnine. Hot
saline baths and hot sponging were used a good deal and were found most useful,
relieving restlessness and headache, lowering the body temperature and pro-
moting sleep. Lumbar puncture is essential, both as regards diagnosis and

94 Clinical and other Notes

treatment ; I have used Barker's needles and canulas, no syringe being used to
withdraw fluid.

Senim Treatment. — The result of serum administration in the earlier cases
was unsatisfactory, in fact the use of it was discontinued for a time. From April
to October, 1915, Flexner's serum was used with fairly good results. During
1916 and 1917 reliance has been chiefly placed on lumbar puncture and the
administration of serum. The Lister Institute serum has been employed for
mihtary cases, with a few exceptions. For civilian cases, " Burroughs
Wellcome" and "Mulford" sera have been employed. In the severest cases,
in addition to intrathecal doses, serum has been given intravenously, with saline
solution. The administration of adrenalin, ten minims every four hours, hypo-
dermically for twenty-four hours, in cases with purpuric rashes and also for
haematuria, has given very promising results.

In some cases the result of serum seemed remarkable, and in my opinion,
with serum-treated cases, there is more rapid recovery in severe cases, and less
likelihood of relapses and sequelae. The serum is warmed before use and allowed
to run in by gravity through the canula vpith funnel and tubing, the amount of
the dose being determined by the amount of the cerebrospinal fluid withdrawn.
r think it is advisable never to insert as much serum as cerebrospinal fluid with-
drawn, forty to fifty cubic centimetres being a maximum dose at one administra-
tion for an adult. Chloroform was the anaesthetic usually given when necessary
for lumbar punctures. I have tfot seen any reason to abstain from giving an
anaesthetic in these cases ; where serum is to be administered it is better given
under an anaesthetic. In the severe cases with rigidity, it is often impossible to
puncture without an anaesthetic. In mild cases, where no serum was to be
administered, or simply for diagnostic purposes, it was generally quite easy to

puncture without an anaesthetic.

Nursing.
The importance of skilled nursing in cases of cerebrospinal fever cannot be
overrated and the recovery of several of our patients must be attributed to the
constant care and attention they received from the matron and nursing staff of

the hospital.

Direct Infection.

The following cases are examples of direct infection : —

(1) F. E., aged 3| years, was admitted to hospital on February 10, 1915, with
a history of one day's illness. L. E., aged 3i, a twin brother of F. E., was
admitted on the same day, February 10, 1915, with a history of five days' illness.
Both had occupied the same bed ; both died,

(2) E. D., aged 27, was admitted to the hospital January 16, 1915, with a
history of a few hours' illness ; ten days later, her mother, Mrs. D., was admitted,
and on the same day the fiance of E. D., a Canadian corporal, was admitted into
a military hospital, suffering from cerebrospinal fever. Mrs. D. and the corporal
were present when E. D. was removed, and both of them may have kissed or
embraced her. All these cases proved fatal.

(3) A little boy, B. H., aged 5 years, died after a very brief illness on
December 30, 1916. He was found to be suffering from cerebrospinal fever. On
December 31, 1916, A. H. (brother of B. H.), aged 7 years, was admitted to
hospital suffering from cerebrospinal fever. He recovered. The brothers had
been sleeping together.

Reviews 95

During 1917 investigations regarding the type of meningococcus found in
military cases were undertaken by the bacteriologists of the Military Hospital,
Sutton-Veny. In addition to the positive cases, there were admitted, with
symptoms suggesting cerebrospinal fever, 141 cases. Of these, twenty were
civilian and 121 military cases. The larger number of military cases may be due
to the fact that soldiers with symptoms suggesting cerebrospinal fever are at once
sent to hospital. In the civilian cases, as a rule, the disease is fairly definite on
admission. Mild cases of cerebrospinal fever in civilians may possibly be over-
looked, and if this be so, probably the apparently higher recovery rate of the
military positive cases maj be attributed co this cause. The ultimate diagnosis
of twenty civilian cases admitted as (?) cerebrospinal fever and found not to be
cases of the disease was as follows: Influenza, 5; pneumonia, 7; bronchitis, 1 ;
gastro-enteritis, 1 ; hysteria, 1 ; tubercular meningitis, 2 ; tonsillitis, 1 ; cerebral
tumour, 1; poliomyelitis, 1.

In all cases, excepting the two cases of tubercular meningitis, the cerebro-
spinal fluid was clear, and nothing was found on examination. The final diagnosis
of 121 military cases admitted as (?) cerebrospinal fever in which the original
diagnosis was not confirmed were as follows : Influenza, 40 ; sunstroke, 3 ;
concussion of brain and spine, 4 ; dental caries, 1 ; dilated heart, 1 ; epilepsy, 3 ;
pneumonia and broncho-pneumonia, 13 ; scarlet fever, 4 ; tonsillitis, 5 ; otitis, 2 ;
pericarditis, 1 ; appendicitis, 1 ; measles, 3 ; malaria, 1 ; loss of memory, 1 ;
myalgia, 4 ; renal disease, 3 ; cerebrospinal fever contact, 1 ; bronchitis, 7 ;
vaccinia, 5 ; gastritis, 2 ; neuralgia, 2 ; rheumatism, 5 ; anti-typhoid inoculation
5 ; headache, 3.

Dr. Ord has kindly allowed me to give particulars relating to eighteen of the
earlier cases who were under his care at the Salisbury Infirmary.

I must also express my thanks to my colleagues in Salisbury for their assist-
ance in administering anaesthetics when necessary, and also to the bacteriologists
of the Military Hospital, Sutton-Veny.

TRcviews.

EoLL OF Commissioned Officers in the Medical Service of the British Army.
By the late Colonel William Johnston, C.B. Aberdeen : University Press.
1917. Pp. Ixxii and 638. 10^ x 7f .

To many of the older ofiicers of the Royal Army Medical Corps this volume
has an interest apart from its avowed object, in that it was a labour of love on
'the part of a well-known, highly and justly esteemed oflicer of the Corps, to
whom we owe much more than most of us recognize, even those with some
fragments of knowledge on the subject.

The personal note contributed by Sir William Babtie, V.C, with the biblio-
graphy of Johnston's work, explains why his memory is so respected — for his
personal qualities and for the work he did.

The Roll covers the period June, 1727, to June, 1898, and it is of course
essential for the proper understanding of the Roll itself, that some account should
be given of the vicissitudes of the Medical Services of the Army at various times.
This is naturally technical to a considerable degree and not very easy reading,
but one has the impression that part of this ground has been surveyed — more in
outline — by other authors in previous articles ; if not, it appears desirable that
Lieutenant-Colonel H. A. L. Howell should supply such a sketch, for which
there is no one better qualified. The development to its present stage of the

96 Beviews

Eoyal Army Medical Corps is now more than a Corps concern ; and " something
to be read and understood by the general public would be of exceptional interest.
There is, of course, a good deal about one period (not the least interesting) in the
life of Florence Nightingale — probably that period of the Nineteenth Century at
which the greatest stimulus was given. But for the older men Colonel Johnston's
account revives memories of old contests, old controversies, many of which now
seem trivial, though all were stages in evolution.

Of the EoU itself it is difficult to speak except in recognition of the ability,
labour and determination necessary for its compilation. It happens that the
volume opened casually at pp. 322, 323, i.e., 1842-43, and the name of Sir Thomas
Longmore appears under 1843, the first on the Eoll of those whom the reviewer
knew personally, though Edmund Alexander Parkes and Sir William Muir are
known to many — one as a leader in modern hygiene and the other as a great
Director-General. As the Eoll goes on — one's personal acquaintances (from a
very humble position) increase very slowly, but the known names rapidly, till one
reaches the period when the men one served under appear — and memories of
companionship and occasional antagonism arise. Eecollections of old stories,
and the thousand and one incidents of one's life, revive — it suggests the tension
of the Day of Judgment, which cannot be unmixed with Homeric laughter unless
a sense of humour is essentially a bodily quaUty.

The pity of it is that no young ofiScer can get the full value of the book, though
every one should see what bis predecessors have done. After all there were
brave men before Agamemnon.

The book has been ably edited by Lieutenant-Colonel Howell, who shows how
the work, incomplete at the time of Colonel Johnston's death, was carried on by
his hands and by Colonel Peterkin, C.B., with assistance from others named.

Every Eoyal Army Medical Corps Mess and Library, and all Service Clubs
should possess this Eoll. R- J- S. S.

The Fitting Out and Administration of a Naval Hospital Ship. By Fleet
Surgeon E. Sutton, E.N. Published by John Wright and Sons, Ltd.,
Bristol, 1918. Price 8s. Pp. vi + 110, 5f x 8|.

This small book on fitting out and administration of a Naval Hospital Ship is
divided into four sections. Section I is historical and also gives International
Law relating to hospjtal ships and the Geneva Convention. Section II gives in
detail the conversion and fitting out of a typical hospital ship. These two
sections are an excellent summary and guide on ihe points to which they refer.

Sections III and IV, comprising more than half the book, give details of organ-
ization. The embarkation and disembarkation routine are fully described as
regards naval routine. As the rest of the book is applicable to hospital ships of
the Army as well as the Navy, it is a pity that the Army routine of embarkation,
disembarkation and distribution of the patients to various hospitals is not given,
as it would have made the book of more general value.

Elements of Field Hygiene and Sanitation. By Joseph H. Ford, B.S., A.M.,
M.D., Colonel, Medical Corps U.S. Army. London : William Heinemann,
Ltd. 1918. Pp. 248, with Index. 8vo. Price 6s. net.

This book is a very useful addition to the library of practical war sanitation.
Some of the methods and illustrations have been taken from Lelean's " Sanitation
in War," but there is also much that is new. The last chapter on illustrative
regulations concerning field hygiene and sanitation are worth issuing to every
officer and senior N.C.O. in all Allied armies. The diagrams of constructional de-
tails at the end of the book should find a place in the Field Service Pocket Book.

The general text of the book is written to be understood by the combatant
officer, and is full of practical suggestions. The work should be of considerable
assistance to the sanitary officer in preparing lectures and giving instruction to
effective troops. Photographs and diagrams are clear and well reproduced ; the
subject matter is well pi'inted.

JOURNAL

OF THB

ROYAL ARMY MEDICAL CORPS.

July, 1918.

EXTRACTS FROM THE "LONDON GAZETTE."

War Office,

May 18, 1918.
The Government of India has forwarded the following list of Officers, whose names have been
brought to notice by Lieut. -Geu. Sir A. A. Barrett, K.C.B., K.C.S.I., K.C.V.O., for valuable
services rendered during the operations against the Mahsuds, March — August, 1917 : —

Medical Services.
Lieut. -Col. L. Addams-Williams, Royal Army Medical Corps.
Lieut. -Col. P. H. Faulkner, Royal Army Medical Corps.
Capt. J. M. Weddell, Royal Army Medical Corps.

War Office,

May 20, 1918.
The following despatch has been received by the Secretary of State for War from Field-
Marshal Sir Douglas Haig, K.T., G.C.B., G.C.V.O., K.C.LE., Commander-in-Chief of the
British Armies in France : —

General Headquarters,

April 7, 1918.
My Lord, — I Jiave the honour to submit the names of the Officers, serving, or who have served,
under my command during the period September 25, 1917, to midnight, February 24/25, 1918,
whose distinguished and gallant services and devotion to duty I consider deserving of special
mention.

I have the honour to be, my Lord,
Your obedient Servant,

D. Haig, Commander-in-Chief, *

The British Armies in Fraiice.
Staff.

Major and Brevet Lieut.-Col. E. Ryan, D.S.O., Royal Army Medical Corps.

War Office,

May 13, 1918.
His Majesty the King has been graciously pleased to approve of the following awards to the
undermentioned Officers, in recognition of their gallantry and devotion to duty in the Field : —

Awarded the Military Cross.
Temp. Qmr. and Hon. Lieut. Robert Leslie blasters, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty when a camp and some billets were heavily
shelled by the enemy. He at once went to the rescue of some men who had been buried in the
ruins of a house, and rendered first-aid. He then organized bearer parties from among his men,
and brought in four severely wounded men from the camp. By his disregard of danger, quick
decision, and good leadership, he set a splendid example to his men, and rendered valuable
assistance to the wounded in the absence of a medical officer.

Temp. Capt. Henry Drummond Robb, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. On his camp and its vicinity being heavily
shelled he was compelled to conduct his sick parade along the roads which were at the time
under heavy shell fire. He succeeded in leading his wounded cases safely under cover, and later
remained behind to attend to the men of a neighbouring unit, which had also sufiered some
casualties as a result of the intense shelling. His courage and devotion to duty were of the
highest order.
Temp. Capt. Samuel Rutherford, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. During a period of sixteen hours he tended
the wounded in the front trenches without ceasing. Throughout this period he was exposed to
heavy shell fire, and for some considerable time the enemy were within a short distance of the
aid post. His coolness and presence of mind inspired all ranks with the utmost confidence.

Mentions in Dispatches.

Mesopotamia.

War Office,

May 11, 1918.
The following names are added to the list of Officers, Warrant and Non-commissioned
Officers and Men, Ladies and Civilians whose services have been brought to notice as deserving
of special mention by the late Lieut. -Gen. Sir Stanley Maude, K.C.B., Commander-in-Chief,
Mesopotamian Expeditionary Force, in his dispatch (published in the London Gazette. No. 30233^
dated August 15, 1917) :—

Capt. A. J. Evans, F.R.C.S.Edin., Royal Army Medical Corps (T.F.).
Temp. Capt. A. T. Gibb, Royal Army Medical Corps.

Corrigenda to " Mentions in Dispatches.'
Egypt.
Under Royal Army Medical Corps (p. 802) : —
No. 29380 Cpl. (Acting Serjt.) J. E. Aynsley.

Mesopotamia.
Supplement to the London Gazette, No. 29810, dated November 1, 1916. Under Royal Army
Medical Corps (p. 10618) :—

Temp. Hon. Capt. W. R. Thomas, Royal Army Medical Corps.

Supplement to the London Gazelle, No. 30570, dated March 12, 1918. The name of the
undermentioned should read as now stated, and not as previously published. Under Royal Army
Medical Corps (p. 3117) :—

No. 25648 Serjt. J. H. Jones.

War Office,

May 25, 1918.
The following is a continuation of Sir D. Haig's dispatch of April 7, submitting name*
deserving of special mention : —

Army Medical Service.

Headquarters Staff,
Lieut.-Gen. Sir A. T. Sloggett, K.C.B., K.C.M.G, K.C.V.O., F.R.C.S., K.H.S.
Major-Gen. C. H. Burtchaell, C.B., C.M.G., M.B.
Major-Gen. Sir W. G. Macpherson, K.C.M.G., C.B., M.B., K.H.P.
Temp. Capt. J. Biggam, M.B., Royal Army Medical Corps.

Major R. B. Black, D.S.O., M.B. (Reserve of Officers), Royal Army Medical Corps.
Lieut. -Col. W. R. Blackwell, Royal Army Medical Corps.
Capt..L. G. Bourdillon, D.S.O., M.C., Royal Army Medical Corps.
Col. H. A. Bray, C.M.G., Royal Army Medical Corps.
Capt. A. D. Child, M.B., Royal Army Medical Corps (Special Reserve).
Col. R. W. Clements, D.S.O., M.B.

Lieut.. Col. (Temp. Col.) H. CoUinson, D.S.O., M.B. , F.R.C.S., Royal Army Medical Corps.
Major (Acting Lieut.-Col.) P. Davidson, C.M.G., D.S.O., M.B., Royal Army Medical Corps.
Capt. K. K. Drury, M.C., M.D., Royal Army Medical Corps (Special Reserve).
Capt. T. I. Dunn, M.C., M.B., Royal Army Medical Corps (Special Reserve).
Temp. Capt. M. du B. Ferguson, M.D., Royal Army Medical Corps.
Lieut.-Col. (Temp. Col.) R. S. H. Fuhr, C.M.G., D.S.O., Royal Army Medical Corps.
Lieut.-Col. (Temp. Col.) J. S. Gallic, D.S.O., Royal Army Medical Corps.
Lieut.-Col. and Brevet Col. (Temp. Col.) T. W. Gibbard, M.B., K.H.S., Royal Army Medicai
Corps.

Temp. Capt. R. E. Gibson, M.B., Royal Army Medical Corps.
Lieut.-Col. T. A. Granger, M.B., Indian Medical Service.
Temp. Capt. S. S. Greaves, M.C., Royal Army Medical Corps.
Lieut. Col. (Temp. Col,) J. Grech, D.S.O., Royal Army Medical Corps.

Capt. A. H. Heslop, D.S.O., JJ.B., Royal Army Medical Corps.

Lieut.-Col. H. C. K. Hime, D.S.O., M.B., Royal Army Medical Coros.

Col. W. E. Hudleston, D.S.O.

Lieut. -Col. (Temp. Col.) L. Humphry, C.M.G., Royal Army Medical Corps.

Temp. Capt. H. G. Kilucr, M.B., Royal Army Medical Corps.

Col. Sir W. B. Leishmau, C.B., F.R.S., M.B., F.R.C.P., K.II.P.

Major (Temp. Col.) C. 11. Liudsay, C.M.G., M.D., Royal Army Medical Corps.

Capt. J. G. McCutcheon, M.B., Royal Army Medical Corps (Special Reserve).

Col. S. Macdonald, C.B., C.M.G., M.B.

Lieut. -Col. and Brevet Col. A. J. ^lacnab, F.R.C.S., ludian Medical Service.

Lieut. Col. J. F. Martin, C.M.G., M.B.

Col. P. J. Morgan, C.M.G.

Lieut. -Col. (Temp. Col.) E. M. Morphew, D.S.O. , Royal Army Medical Corps.

Col. D. M. O'Callaghan, C.M.G.

Surg. -Gen. M. W. O'Keeffe, C.B., M.D.

Lieut. -Col. (Temp. Col.) G. J. A. Ormsby, M.D., D.S.O., Royal Army Medical Corps.

Major (Temp. Lieut. -Col.) E. T. Potts, D.S.O., M.D., Royal Army Medical Corps.

Temp. Capt. G. Rankine, M.C., M.B., Royal Army Medical Corps.

Col. (Temp. Surg.-Gen.) B. M, Skinner, C.B., C.M.G., M.V.O.

Capt. O. W. D. Steel, M.C., Royal Army Medical Corps.

Col. G. St. C. Thorn, C.M.G., M.B.

Lieut.-Col. (Temp. Col.) A. G. Thompson, D.S.O., M.B., Royal Army Medical Corps.

Major-Gen. H. N. Thompson, C.B., C.M.G., D.S.O., M.B.

Capt. L. R. Tosswill, Ro3'al Army Medical Corps.

Capt. L. R. Turner, Roj'al Army Medical Corps.

Major (Temp. Lieut.-Col.) D. P. Watson, M.B., Royal Army Medical Corps.

Temp. Capt. R, H. G. Weston, M.B., Royal Army Medical Corps.

Consultants.
Major (Temp. Lieut.-Col.) H. A.Ballance, M.D., F.R.C.S.
Temp. Major-Gen. Sir A. A. Bowlby, K. C.M.G., K.C.V.O., F.R.C.S.
Temp. Major-Gen. Sir J. R. Bradfo'rd, K. C.M.G., C.B., F.R.S., M.D
^lajor R. H. Cooper, Royal Army Medical Corps.
Temp. Major-Gen. Sir B. E. Dawson, G.C.V.O., C.B., M.D.
Major (Temp. Col.) H. McI. W. Gask, C.B., M.B., F.R.C.S.
Major (Temp. Col.) H. McI. W. Gray, C.B., M.B., F.R.C.S.
Col. E. M. Pilcher, D.S.O., M.B. , F.R.C.S.
Temp. Col. 0. W. Richards, D.S.O., M.D., F.R.C.S.
Temp. Col. T. Sinclair, C.B., F.R.C.S.

Lieut-Col. (Temp. Col.) C. B. Thorburu, C.B., M.D., F.R.C.S.
Temp. Major-Gen. C. S. Wallace, C.M.G.

Capt. (Temp. Col.) A. E. Webb-Johnson, D.S.O., M.B., F.R.C.S. -
Temp. CoL Sir A. E. Wright, C.B., M.D., F.R.C.S. I., F.R.S.

Royal Army Medical Cobps.

Temp. Capt. J. Alexander, M.B. Temp. Lieut. J. S. Clark, M.B.

Temp. Capt. A. S. K. Anderson, D.S.O., M.C., ] Capt. (Acting Lieut.-Col.) C. Clarke, M.B

M.B. F.R.C.S.

Temp. Capt. J. S. Arkle, M.B. Temp? Capt, C. J. W. Clayton.

Qmr. and Hon. Major H. J. F. Audus. I Major T. S. Coates, M.B.

Temp. Capt. C. C. Austen. Temp. Capt. C. G. Colyer.

Temp. Capt. T. B. Batchelor. Temp. Capt. J. A. Conway, M.C., M.D.

Qmr. and Temp. Lieut. V. A. Bell. ^r ■ ^ ^^ ^
Temp. Capt. W. C. Blackham, M.B.

Temp. Capt. A.- D. Blakeley, M.B. ^ ^..

Capt. (Acting Lieut.-Col.) W. W. Boyce. Temp. Capt. J. Crawford, M.C.
Temp. Capt. C. F. Brady, M.B. Qmr. and Hon. Capt. F. C. Cross.
Temp. Qmr. and Hon. Capt. B. G. Brook. ' Temp. Capt. J. M. D. Cruickshauk.
Temp. Capt. G. M. Brown, M.B. Capt. (Temp. Lieut.-Col.) F. W. ]\L Cunning-
Major (Acting Lieut.-Col.) C. G. Browne, D.S.O. ham, M.D.

Qmr. and Hon. Major E. J. Buckley. Major (Acting Lieut.-Col.) J. Dalrymple.
Temp. Hon. Lieut.-Col. H. Cabot. Temp. Lieut.-Col. C. G. Douglas, M.C, M.D.
Temp. Capt. J. P. Cahir, M.B. Temp. Capt. (Acting Lieut.-Col.) R. E. Drake-
Temp. Capt. S. B. B. Cambell, M.B. Brockman.

Temp. Capt. T. H. Cambell, M.B. Lieut. (Temp. Capt.) C. R. Dudgeon, M.C.

Temp. Capt. H. M. B. Caplan. Temp. Lieut.-Col. (Lieut.-Col., Aust.A.M.C),

Temp. Capt. P. F. Carr-Harris, D.S.O., M.D. W. J. E. Eames, C.B., M.D.

Temp. Capt. M. T. Cassidy, M.B. Temp. Capt. G. D. Eccles.

Temp. Capt. A. W. S. Christie, M.B. \ Temp. Capt. J. A. Edmund.

Major R. H. Cooper.
Temp. Capt. G. M. Cowper.
Temp. Capt. W. Crabtree, M.B.

Temp. Capt. H. Emerson, M.C., M.B.
Qmr. and Hon. Capt. C. A. Figg.
Temp. Capt. C. C. Forsyth.
Temp. Capt. D. S. Graham.
Temp. Capt. H. B. Graham, D.S.O., M.B.
Temp. Capt. A. Gray, M.D.
Major (Acting Lieut. -Col.) G. D. Gray, M.D.
Qmr. and Hon. Major J. Green.
Major (Temp. Lieut.-Col.) R. C. Hallowes.M.B.
Lieut. -Col. A. E. Hammerton, D.S.O.
Temp. Capt. C. Harris.

Lieut.-Col. (Temp. Col.) J. A. Hartigan, D.S.O.
Major (Temp\ Lieut.-Col.) T. E. Harty, D.S.O.
Major (Temp. Lieut.-Col.) W. J. S. Harvey,
D.S.O.
. Capt. (Acting Lieut.-Col. R. Hemphill, M.B.
Temp. Capt. F. W. Hird, M.B.
Major J. E. Hoar.

Temp. Qmr. and Hon. Capt. T. W. Jent.
Temp. Capt. L. C. Johnson.
Temp. Capt. (Acting Lieut.-Col.) A. Jones,

M.C., M.D.
Temp. Capt. W. D. Kennedy, M.B.
Temp. Qmr. and Hon. Lieut. E. Kerstein, M.C.
Temp. Hon. Major L. F. B. Knuthsen,

R.A.M.C.
Temp. Capt. P. J. Lane, M.C, M.B.
Temp. Capt. R. M. Lang, I\LB.
Qmr. and Hon. Lieut. H. B. Lee.
Temp. Capt. R. D. Lemon, M.B.
Temp. Qmr. and Hon. Lieut. P. le Poidevin.
INIajor (Acting Lieut.-Col.) R. P. Lewis.
Temp. Capt. G. A. Lilly.
Temp. Capt. S. J. L. Lindeman.
Temp. Capt. W. H. Lister, D.S.O., M.C.
Temp. Capt. A. L. Lockwood, M.C. M.D.
Major J. L. London, M.B.
Temp. Capt. P. A. MacCullum, M.B.
Temp, Capt. S. E. McClatchlv, M.B.
Temp. Capt. J. W. Macfarlane, M.C, M.B.
Temp. Capt. R. McGrath, M.B.
Temp. Qmr. and Hon. Lieut. J. B. Mackav.
Temp. Capt. R. A. MacNeill, M.B.
Temp. Capt. A. C. B. McMurtrie, F.R.C.S.,

M.D.
Temp. Capt. W. R. P. McNeight, M.D.
Capt. (Acting Lieut.-Col.) A. N. R. McNeill,

M.B.
Temp. Lieut.-Col. A. Martin-Leake, V.C,

F.R.C.S.
Temp. Capt. A. F. Mavety, M.B.
Temp. Qmr. and Hon. Lieut. H. Miller.
Temp. Capt. D. M. Morison, M.B.
Temp. Capt. J. ISIorrison, M.B.
Temp. Capt. H. H. P. Morton.
Capt. W. P. Mulligan. M.B.
Capt. W. G. Mumford, M.B., F.R.C.S.
Major (Acting Lieut.-Col.) C. D. "Myles, M.B.
Temp. Capt. G. E. Nicholls, M.B.
Capt. (Acting Lieut.-Col.) T. B. Nicholls, M.B.
Temp. Hon. Capt. H. Nockolds, M.B.
Capt. (Acting Lieut.-Col.) J. J. O'Keefie, M.C,

M.B.
Major (Temp. Lieut.-Col.) A. C Osburn, D.S.O.
Qmr. and Hon. Capt. (Acting Major) J. T.

Capt. E. Phillips, M.C, M.B.
Temp. Capt. F. E. L. Phillips.
Temp. Capt. J. G. Pigott.

Lieut.-Col. J. Powell, M.B.

Temp. Capt. J. A. Pringle, M.D.

Temp. Capt. J. Proctor, M.B.

Temp. Capt. (Temp. Lieut.-Col.) C D. Pve-

Smith, D.S.O., M.C, F.R.C.S., M.B.
Temp. Capt. C R. Reckitt.
Temp. Capt. G. W. Riddel, M.B.
Temp. Capt. A. C Rowswell, M.B.
Capt. (Acting Lieut.-Col.) C Scaife, M.D.
Temp. Capt. C Scales, M.D.
Qmr. and Hon. Capt. E. B. Senior.
Temp. Capt. (Acting Lieut.-Col.) L. D. Shaw,

D.S.O., M.B.
Major (.\cting Lieut.-Col.) H.C Sidgwick. M.B.
Major M. Sinclair, M.B.

Temp. Qmr. and Hon. Lieut. E. B. Snowden
Qmr. and Hon. Lieut. E. B. Steele.
Major (Acting Lieut.-Col.) W. L. Steele.
Temp. Lieut.-Col. G. N. Stephen.
Temp. Capt. D. S. Taylor.
Major (Acting Lieut.-Col.) C H. Turner, D.S.O.
Temp. Capt. G. W. Twigg, M.D.

Major (Acting Lieut.-Col.) T. B. Unwin, M.B.

Capt. (Acting Lieut.-Col.) E. W. Wade, M.B.
Temp. Capt. W. Warburton, M.B.
Major (Acting Lieut.-Col.) W. J. Waters.
Capt. W. L. Webster, M.B.
Temp. Capt. W. W. Wells, M.B.
Temp. Capt. C R. Whittaker, F.R.C.S.

Temp. Capt. D. R. Williams.

Temp. Capt. R. L. Williams, M.C.

Qmr. and Hon. Capt. P. Wilson.

No. 77055 Serjt. G. W. Ames.

No. 339026 Serjt. C Atherton.

No. 193-36 Cpl. (Acting Staff-Serjt.) A. Barnes.

No. 13338 S. M. .Boxhall, H.S.

No. 42527 Pte. (Acting Cpl.) R. H. Bradbury.

No. 71956 Pte. (Acting Serjt.) J. W. Briggs."

No. 16756 StafE-Serjt. (Acting Qmr.-Serjt.)
N. W. Brown.

No. 40423 Pte. (Acting Serjt.) F. J. Burgess.

No. 62700 Serjt. F. E. Buxton.

No. 18061 Staff-Serjt. (Acting Serjt.-Major)
W. Cairns.

No. 48925 Pte. (Acting Cpl.) A. Channing.

No. 4S097 Pte. A. E. Chave.

No. 61883 Cpl. (Acting Serjt.) E. G. Clegg.

No. 38125 Cpl. (Acting Serjt.) A. C Darbyshire.

No. 65323 Pte. (Acting Serjt.) D. T. Davidson.

No. 27943 Pte. A. Dickinson.

No. 53674 Cpl. (Acting Qmr.-Serjt.) H. Duke.

No. 90487 Pte. (Acting Cpl.) S. A. Dyer.

No. 77071 Pte. (Acting Serjt.) H. Evans.

No. 19688 StafE-Serjt. (Acting Serjt.-Major)
T. V. Falkingham.

No. 15312 Serjt. G. Gillespie.

No. 54843 Cpl. R. B. Graham.

No. 717.38 Pte. T. Hacking.

No. 89674 Pte. J. Hadfield.

No. 17212 Pte. (Acting Cpl.) F. Haskell.
' No. 90454 Staflf-Serjt. A. Hay.

No. 63912 Serjt. (Acting Stafi-Serjt.) D.
Jeffreys.

No. 48311 Serjt. G. J. Jones.
1 No. 54078 Serjt. (Acting Qmr.-Serjt.) W,
I Keighley.

j No. 54640 Serjt. (Acting Qmr.-Serjt.) H.
Kirwan.

No. 1659 Pte. (Acting Cpl.) J. Loram.

No. 17632 Qmr.-Serjt. H. C. A. Luun.
No. 45969 Serjt. G. Mackay.
No 32950 Pte. T. McWlmnnel.
No. 54443 Sorjt. H. Mellor.
No. 320119 Cpl. A. Mennio^
No. 16397 Staff-Serjt. W. G. Mills.
No. 4G711 Pte. J. Monaghan.
' No. 640 Pte. A. Nixon.
No. 1278 Pte. I. Parker.
No. 75280 Sorjt. S. R. Paskm. ,

No. 19126 Serjt. (Acting Serjt.-Major)

Perkins.
No. 10031 Pte. W. Penman
No. 32964 Serjt. (Acting Staff-Serjt.)
Preston.

Rainey.

F. H.

F. E.

W. C.

No. 69111 Pte. (Acting Cpl.) M. H. Rowe.

No. 37022 Cpl. J. Simpson.

No. 76432 Cpl. (Acting Lance-Serjt.)

Smith.
No. 8861 Serjt. E. Steffens.
No. 5731 Pte. (Acting Cpl.) T. Thome.
No. 2276 Pte. (Acting Cpl.) D. Torrance.
No 35182 Pte. H. Stansfield.
No. 15967 Sorjt. W. T. Tringham.
No. 58655 Cpl. F. Turner.
No. 5134 Serjt. A. Vaughan.
No. 72533 Pte. (Acting Lance-Cpl.)

Watson.
No. 90437 Pte. (Acting Lance-Cpl.)

Williams. . ^ f^^-. .

No. 12185 Staff-Serjt. (Actmg Qmr.-Serjt.)

A. S. Willis.

F. A.
J. E.

M.B.

No. 41193 Pte. J . , . -r t,- , a

No. 59112 Pte. (Acting Cpl.) L. Richards.

Royal Army Medical Corps.
,rT3 Capt. W. McK..H.McCullagh,

Capt. W. R. Blore, M.B. ^"V

Capt. C. F. Burton.
Caut W. B. Cathcart, M.B.
Capt'. E M. Cowell, M.D.. P.RX.S.

Capt T. G. Fleming, M.C., M.B.

Capt. F. H. Goss, M.B.

Capt. R. A. Greenwood, M.B.

Capt. (Aeting Lieut.-Col.) C. J. A. Griffin.

Capt. T. F. Hegerty.M.B

D.S.O., M.C.

Capt. F. Jefferson, M.B.
Capt. J. I. Lawson, M.B.

Capt. (Acting Lieut.-Col.) S. Miller, M.C, M B.

Capt. G.H. C.Mold, M.B.

Capt. (Acting Lieut.-Col.) K. D. Murchison,

D.S.O.,M.B. „„^a

Capt. C. M. Page, M.B., F.R.C.S.
Capt. (Acting Lieut.-Col.) A. T. Pitts.
Ca?t. (Actini Lieut.-Col.) E. T. C. Robertson,

D.S.O., M.B.
Capt. H. G. Trayer, M.B.

Capt. J. W. Anderson, M.C, M.B.

Capt. C. F. Backhouse.

Major T. A. Barron. ^ -r, -d- ;i r. a n

Major (Temp. Lieut.-Col.) E B Bird, D.SX)

Capt. (Acting Lieut.-Col.) W. Blackwood, M.B.

Temp. Capt. L. Blake, M.B.

Qmr^nd Hon. Capt C W. Braithwaite

Capt (Temp. Lieut.-Col.) J. Bruce, M.B.

S^;TASn"gti,t':Col., A. Oallam, M.B.
Capt. 0. Cattlm.

g^i" fAcTinfL?;ut.- Col.) F. G. Dobson, M B.
Capt". Temp^ Lieut.-Col.) C W. Fames, M.D.
Lieut.-Col. W. E. Foggie, M.D. , r^^ \

Capt. and Brevet-Major (Temp^ Lieut.-Col.)

C H S. Frankau, M.B.,F.R.Cb.
Capt. H. N. Goode, M.B., F.R.C.S.
Capt. J. M. Hamill.
Capt. T. R. Kenworthy, ^L(j.
Capt. G. C King.

Capt. G. H. Kirby. ^ .^ „.,,,«■ -R
Capt. (Temp. Major E. Knight, M.B
Capt. (Acting Lieut.-Col.) C L. Lander, M.C,

Capt^ting Lieut.-Col.) H. B. Low, M.C,

Capt. (Acting Lieut.-Col.) Macjcie

Capt. (Actini Lieut.-Col.) J. MacMiUan, M.C

M.B.
Capt. S. A. S. INIalkin.

?S»tTemp.'Ll:utcoM J. Nigbti„g»le, M.D

Capt. R. P. Pollard, M.B.

Qmr. and Hon. Lieut. T. Priest.

Capt. H. H. Robinson, M.C.

Capt. F. E. W. Rogers.

Capt. S. Scott, M.B.

Royal Army Medical Corps (T.F.).

Smith, M.B

C. A. A. Stidston

W. G. Sutcliffe»

J. WiUiamson,

Capt. J. M .

Major (Temp. Lieut. -Col.)

D.S.O., M.D.
Capt. W. Stobie, M.B.
Major (Temp. Lieut.-Col.)

F.R.C.S.
Capt. A. C. Watkiu.
Capt. (Acting Lieut.-Col.) A.

MaJo?"(Temp. Lieut.-Col.) P. G. Williamson,

M.C, M.B.
No. 435439 Pte. F. Bayman.
No. 527013 Staff-Serjt. H. Body.
No. 405272 (Acting Cpl.) W. Briggs.
No. 536010 Serjt. F. Burndge.
No. 493723 Cpl. W. Chick
No. 412002 Staff-Serjt. L. H. Clarke.
No. 305012 Serjt. J. R. Crabbe.
No. 337283 Serjt.-l\Iajor F. Fowles.

No. 403176 Pte. H. B. Garhck.

No 461344 Cpl. C R. Garrett, M.M.

No 495191 Staff-Serjt. P. W. Glover.

No. 527784 Acting Serjt. F. A Green

No. 461281 Serjt. (Acting Staff-Sergt.) H. H.
Hayward.

No 546228 Pte. C E. Laugham.

No. 403650 Pte. E. INIcWilhams.

No. 417083 Cpl. A. Moran. .

No. 380014 Qmr.-Serjt. (Temp. Serjt.-Major)

No.* 497317 Serjt. (Actiaag Staff-Serjt.) E. R.

No. 339033 Serjt. (Acting Staff-Serjt.) A. Sand-
ham.
No. 350236 Serjt. D. Shirt.
No. 512323 Serjt. W. C. S. Smither.
No 426123 Pte. H. Walkerdinc.
No. 527209 Pte. (Acting Cpl.) V. C. Wheeler.

War Office,

May 30, 1918.
The following dispatch has been received by the Secretary of State for War from General
Sir Herbert Plumer, G.C.B., G.C.M.G., G.C.V.O., A.D.C. :—

Headquarters,
Aijril 18, 1918.
My Lord, — I have the honour to submit a list of names of these officers, non-commissioned
officers, and men, serving, or who have served, under my Command, whose distinguished and
gallant services and devotion to duty I consider deserving of special mention,

I have the honour to be, My Lord,

Your obedient Servant,

Hebbeut Pldmeb, General.
Abmy Medical Seevice.

Staff.
Col. R. J. Blackham, C.M.G., CLE., D.S.O., M.D.
Col. S. L. Cummins, C.M.G., M.D., Royal Army Medical Corps.
Col. J. V. Forrest, C.M.G. , Royal Army Medical Corps,
Lieut. -Col. C. H. Furuivall, Ro3-al Army Medical Corps.
Capt. T. D. Inch, M.C., M.B., Royal Army Medical Corps.
Col. L. N. Lloyd, C.M.G., D.S.O., Roval Army Medical Corps.
Major-Gen. F. R. Newland, C.B., C.M.G., M.B.
Temp. Capt. W. J. Pearson, M.C., M.B., Royal Army Medical Corps.
Lieut.-Col. (Temp. Col.) R. Pickard, C.M.G., M.B., Roval Army Medical Corps.
Col. T. du B. Whaite, C.M.G., M.B.

Royal Abmy ^Medical Cobps,

Temp. Qmr. and Hon. Lieut. E. G. I. Brice.

Temp. Capt. W. E. Bullock, M.D.

Temp. Capt. P. J. Chissell.

Lieut.-Col. W. C. Croly.

Temp. Capt. S. J. Drake, M.C., M.B.

Temp. Capt. J. S. Davies.

Capt. D. G. Duff, M.B. (Special Reserve).

Temp. Capt. J. S. Dovle.

Temp. Capt. W. Duffy, M.B.

Temp. Qmr. and Hon. Lieut. C. Elliot, M.C.

Temp. Capt. D. G. (iardiner, M.B.

Temp. Qmr. and Hon. Lieut. T. H. Griggs.

Capt. (Acting Lieut.-Col.) A. Irvine-Fortescue,

M.B.
Temp. Lieut. T. B. Johnston, M.B.
Lieut. (Temp. Capt.) T. J. Kelly, M.C.
Temp. Capt. T. L. Llewellyn, M.D.
Capt. H. W. Maltby (Special Reserve).
Capt. T. S. Nelson (Special Reserve).
Capt. (Temp. Lieut.-Col.) T. H. Scott, M.C,

M.B.
Temp. Capt. T. Stordy.
Temp. Capt. T. Thompson.
•Temp. Capt. H. Upcott.

Temp. Capt. R. R. Watts, M.B.

Lieut.-Col. J. W. West, M.B.

No. 295 Staff-Serjt. A. E. Cheer.

No. 4724 Pte. H. F. Davey.

No. 28385 Serjt. W. Greenwood.

No. 100910 ;Pte. (Acting Lance-Cpl.) J. Harte.

No. 83038 Pte. (Acting Cpl.) J. W. Hindley.

No. 10634 Serjt. (Acting Qmr.-Serjt.) F. Horn

No. 10893 Pte. H. M. Howell.

No. 90257 Pte. J. G. Hunter.

No. 14464 Serjt. -Major G. F. Hurran.

No. 34131 Serjt. (Acting Stiff-Serjt.) A. 0. Judd

No. 12694 Cpl. F. McCaffery.

No. 41766 Serjt.-Major J. E. Matthews.

No. 74102 Pte. (Acting Lance-Cpl. )W. J. Moody

No. 66744 Serjt. H. J. Parker.

No. 19161 Staff-Serjt. G. Parkinson.

No. 74683 Serjt. (Acting Qmr.-Serjt.) H

Prince.
No. 59607 Pte. (Acting Lance-Cpl.) J.

Robinson.
No. 30796 Staff-Serjt. L. J. Rowan.
No. 1827 Serjt T. F. Spratt.

Royal Abmy Medical Cobps (Tebbitoeial Fobce).

Capt. L. Ball, M.B.

Capt. (Acting Major) W. Bowater, M.C.

Capt. (Acting Lieut.-Col.) T. A. Green, M.D.,
D.S.O.

Major (Acting Lieut.-Col.) G. H. L. Hammer-
ton, D.S.O. , M.C.

Capt. G. C Soutter, M.D.

Qmr. and Hon. Capt. S. C. Wright.

( 'apt. B. M. Young.

No. 527010 Staff-Serjt. (Acting Serjt.-Major)

S. P. Bristow.
No. 437192 Serjt. E. J. Bryden.
No. 435003 Staff-Serjt. A. Owen.

Centbal Chanceby of the Ordees of Knighthood.

' St. James's Palace, S.W.,

June 3, 1918.
His Majesty the King has been graciously pleased, on the occasion of His Majesty's Birthday, to
give orders for the following appointment, to the Most Honourable Order of the Bath, for valuable

services reiKlered in connexion with Military Operations in Salonika. Dated June 3, 1918 :

To be Additional ]\Iember of the Military Division of the Third Class, or Companions, of the
said ]\Iost Honourable Order : —

Col. Gerald Thomas Rawnsley, C.M.G., Army Medical Service.

War Office,

June 3, 1918.
His Majesty the King has been graciously pleased, on the occasion of His Majesty's Birthday,
to approve of the undermentioned rewards for distinguished service in connexion with Military
Operations in Salonika. Dated June 3, 1918 : —

To BK Brevet Colonel.
Lieut.-Col. P. J. Brakenridge, C.IM.G., Royal Armv IModical Corps.
Lieut. -Col. (Temp. Col.) W. H. S. Nickerson, V.C., C.M.G., M.B., Royal Army Medical Corps.

To BE Brevet Lieutenant-Colonel.
(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in the
case of Officers belonging to these categories, as applicable.)

Major (Temp. Lieut.-Col.) C. W. Holden, D.S.O., Royal Army Medical Corps.

To BE Brevet Major.

(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in
the case of Officers belonging to these categories, as applicable.)

Capt. W. J. P. Mayne, M.B., Royal Army Medical Corps.

To BE GRANTED THE NeXT HiGHER RaTE OP PaY UNDER THE PROVISIONS OF THE

Royal Warrant.
Qmr. and Hon. Capt. P. A. Baynes, Royal Army Medical Corps.

Awarded the Distinguished Service Order.
Roi/al Army Medical Cor2}s.
Major (Acting Lieut.-Col.) Frederick Joseph

Garland, M.B.
Capt. and Brevet-Major (Acting Lieut.-Col.)

Benjamin Johnson, M.B.
Lieut.-Col. Montagu Marmion Lowslej-.

Capt. (Temp. Lieut.-Col.) Hector Graham Gor-
don IMackenzie, M.B.
Lieut.-Col. John Robert Whait, M.B.
Major Ralph Koper White.
Temp. Major Harold Waterlow Wiltshire, M.D.

Awarded the Military Cross.
Royal Army Medical Corps.

Capt. William Diusdale Anderton,M.B., Special

Reserve.
Lieut. (Temp. Capt.) Desmond William

Beamish.
Captain Eugene Henry Coyne, M.B.
Temp. Capt. Henry Harvard Davis.
Temp. Capt. Leslie Wilson Evans, M.B..

Temp. Capt. Claude Charles Harrison, M.B.
Capt. Wm. Ashley Lethem, i\LB., Spec. Res.
Temp. Capt. John William Riddoch, M.B.
Capt. Frank Hubert Robbins.
Capt. Frank Scroggie, M.B.
Capt. Robert Glen Shaw, M.B.
Capt. Valentine Hutchinson Wardle.

His Majesty the King has been graciously pleased, on the occasion of His Majesty's Birthday,
to approve of the undermentioned rewards for distinguished services in connexion with Jlilitarv
Operations with the British Forces in Salonika : —

Awarded the Distinguished Conduct Medal.

No. 18627 Staff-Sergt. H. Cockburn, Royal Army Medical Corps (Southampton).

His Majesty the King has been graciously pleased, on the occasion of His Majesty's Birthday,

to approve of the award of the Meritorious Service Medal to' the undermentioned Warrant

Officers, Non-commissioned Officers and Men, in recognition of valuable services rendered with

the Forces in Salonika : —

Eoyal Army Medical Corps.

No. 498137 Pte. G. E. Box (Chatham).

No, 32707 Pte. (Acting Staft-Serjt.) A. E.
Brown (Anfield).

No. 497008 Temp. Serjt. -Major H. G. Free-
man (Kingston).

No. 30179 Serjt. -Major L. Hayes (Kew).

No. 54590 Serjt. -Major C. W. Holt, D.C.M.
(Dundalk).

No. 42722 Serjt. -Major S. Jacob (Moseley).

No. 25893 Pte. (Acting Serjt.) E. G.
L'Estrauge (Hastings).

No. 26639 Qmr. -Serjt. (Temp. Serjt. -Major) T.
Liddell (Shircbrook).

No. 39876 Serjt. -Major A. J. Magee (Craghead).

No. 497075 Serjt. W. J. Maskrey (Kingston-on-
Thames).

No. 512130 Pte. (Acting Qmr.-Serjt.) H. P. B.
Owen (Mitcham).

No. 510257 Pte. (Acting Cpl.) F. R. Peni-
chelli (Hammersmith).

No. 11627 Serjt. -Major H. Seeker (Glasgow).

No. 510036 Qmr.-Serjt. J. G. Sinclair (Fins-
bury Park).

No. 527159 Lauce-Cpl. (Acting Serjt.) W. G.
Stan brook (Southend, near Reading).

No. 888258 Cpl. W. Stephenson (Willingtou).

No. 58159 Serjt. (Acting Qmr.-Serjt.) H. S.
Todd (Blavdon).

No. 58216 Serjt. H. C. White (Hastings).

June 3, 1918.

The King has been graciously pleased, on the occasion of His Majesty's Birthday, to signify
His Majesty's intention of conferring the honour of Knighthood on the following :—

Mayo Robson, Esq., C.V.O., P.R.C.S.

For services rendered as Honorary Consulting Surgeon at the King Edward VII Memorial
Hospital, Windsor. Past Vice-President of the Royal College of Surgeons.

^ June 3, 1918.

The King has been graciously pleased, on the occasion of His Majesty"s Birthday, to give
orders for the following promotions in, and appointments to, the Most Honourable Order of the
Bath :—

To be Ordinary Member of the IVIilitary Division of the Third Class or Companion :—

Lieut.-Col. John Blackburn Smith, M.B., Indian Medical Service.

Chancery of the Royal Victorian Order.

St. James's Palace,

June 3, 1918.
The King has been graciously pleased, on the occasion of His ^Majesty's Birthday, to make
the following promotions in, and appointments to, the Royal Victorian Order: —
To be Knight Grand Cross : —
Lieut. -Gen. Sir Alfred Keogh, G.C.B., C.H.
To be Knight Commander : —
Lieut.-Col. Sir Edward Scott Worthington, C.M.G., M.V.O., Royal Army Medical Corps.

Central Chancery of the Orders of Knighthood.

St. James's Palace, S.W. ,

June 3, 1918.
The King has been graciously pleased, on the occasion of His Majesty's Birthday, to give
orders for the following appointinents to the Most Honourable Order of the Bath for services in
connexion with the War, dated June 3, 1918 : —

To be Additional Members of the Military Division of the Third Class, or Companions of the
said Most Honourable Order : —

Col. (Temp. Major-Gen.) George Bradshaw Stanistreet, C.M.G., M.B., Army Medical Service.

Canadian Force.
Col. .\lexander Primrose, Canadian Army Medical Corps.

Chancery of the Order of Saint Michael and Saint George.

Downing Street,

June 3, 1918.

The King has been graciously pleased, on the occasion of His Majesty's Birthday, to give
directions for the following promotions in, and appointments to, the Most Distinguished Order
of Saint Michael and Saint George for services rendered in connexion with the War, dated
June 3, 1918. , , , .^ ,^

To be Additional Members of the Second Class, or Knight Commanders of the said Most
Distinguished Order : — •

Temp. Major-Gen. Sir Berkley George Moynihan, C.B.

Col. William Heaton Horrocks. C.B., M.B. (retired pay). Army Medical Service.

Temp. Col. Sir Ronald Ross, K.C.B., F.R.S., F.R.C.S., Army Medical Service (retired pay),
Indian Medical Service. .

To be Additional Members of the Third Class, or Companions, of the said Most Distin-
guished Order : —

Temp. Col. Arthur Stanley Woodwark, M.D., Army Medical Service.

Lieut.-Col. Francis Stephen Irvine, D.S.O., M.B., Royal Army Medical Corps.

Capt. (Temp. Hon. Lieut.-Col.) Donald John Armour, Royal Army IMedical Corps (Special

Reserve).

Canadian Force.
Col. George Eli Armstrong, Canadian Army IMedical Corps.
Hon. Lieut.-Col. George Washington Badgerow, Canadian Army Medical Corps.

New Zealand Force.
Lieut.-Col. Cyril Hocken Tewsley, New Zealand Medical Corps.

Newfoundland Contingent.
Major Cluny Macpherson, M.D., Royal Newfoundland Regiment.

War Olfice.

Jtme 3, 1918.
The King has been graciously pleased, on the occasion of His Majesty's Birthday, to approve
of the undermentioned rewards for valuable services rendered in connexion with the War,

dated June 8, 1918.

To BE Brevet Colonel.

(On Retired List, Reserve of Officers, New Army, or Territorial Force, in the case of Officers

belonging to these categories as applicable.)

Surg. Lieut.-Col. .1. F. Batoson, M.B. (retired pay), late Coldstream C4uards.
Surg. Lieut.-Col. E. N. Sheldrake (retired pay), late Grenadier Guards.
Lieut.-Col. A. L. A. Webb, C.M.G., Royal Army Medical Corps.
Lieut.-Col. Sir E. S. Worthington, C.M.G., M.V.O., Royal Army Medical Corps.

To BE Bkevet Lieutenant-Colonel.

(On Retired List, Reserve of OtHcers, Special Reserve, Now Army, or Territorial Force, in
the case of Officers belonging to these categories, as applicable. )

j\Iajor P. G. Eaichnie (retired pay), Reserve of Officers, Royal Army Medical Corps.

Capt. and Brevet Major H. M. Rigby, K.C.V.O., M.B., F.R.C.S.. Royal Army Medical Corps.

Capt. and Brevet Major Sir H. J. Stiles, M.B., F.R.C.S., Royal Army Medical Corps (Temp.
Lieut.-Col.), Royal Army Medical Corps.

To BE Brevet Major.
(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in
the case of Officers belonging to these categories as applicable.)
Capt. H. H. Blake, IM.B., Royal Army ]Medical Corps.
Temp. Capt. A. E. Boycott, M.D., P.R.S., Royal Army Medical Corps.
Capt. (Acting Major) A. G. R. Foulerton, F.R.C.S., Royal Army Medical Corps.
Capt. C. C. Frye, Royal Army INIcdical Corps.
Capt. J. Gilmour, M.C., M.B., F.R.C.S.Edin., Royal Army Medical Corps.

To BE Honorary Lieutenant-Colonel.
Qmr. and Hon. Major N. G. Copping (retired pay). Royal Army Medical Corps.
Qmr. and Hon. Major A. Wilson, Royal Army Medical Corps.

To be granted the Next Higher Rate of Pay under the Provisions of the

Royal Warrant.
' Qmr. and Hon. Lieut. W. E. Squire, Royal Army Medical Corps.

June 3, 1918.

His Majesty the King has been graciously pleased, on the occasion of His Majesty's
Birthday, to approve of the award of the Meritorious Service Medal to the undermentioned
Non-commissioned Officer in recognition of valuable services rendered with the British Forces
on the Mediterranean Line of Communications :^

No. 1905 Stafi-Serjt. (Acting Serjt. -Major) J. O. Eves, Royal Army Medical Corps (Whitehall).

Central Chancery of the Orders op Knighthood.

St. James's Palace, S.W.

June 3, 1918.

The King has been graciously pleased, on the occasion of His Majesty's Birthday, to give
orders for the following promotions in, and appointments to, the Most Excellent Order of the
British Empire, for services in connexion with the War.

To be Commander of the said Most Excellent Order : —

Col. William Henry Parkes, C.M.G., Director of Medical Services, New Zealand
Expeditionary Force.

To be Officers of the said Most Excellent Order : —

Lieut.-Col. Alexander Bruce, Army Medical Department, War Office.

Major Edward John Buckley, for service with the British Expeditionary Force in France.

Major Charles Ernest Goddard, M.D., President of a Recruiting Medical Board.

Lieut.-Col. William Ernest Grigor, Australian Army Medical Corps.

Major George Home, Officer in charge of Surgical Division, No. '2 New Zealand General
Hospital.

Major Arthur Hammersley Johnson, M.R.C.S., L.R.C.P.

Major Alexander Lewis Urquhart, Royal Army Medical Corps, for services with the British
Expeditionary Force, Salonika.

Capt. Thomas George Wakeling, President of a Recruiting Medical Board.

Major John Wilson, Officer Clerk, War Office Establishment.

Capt. Alfred HarwQod, Statistical Branch, Department of Director-General, Army Medical
Service. •

St. James's Palace, S.W.

Jinie 3, 1918.

The King has been graciously pleased, on the occasion of His Majesty's Birthday, to give
orders for the following promotions in, and appointments to, the Most Honourable Order of the
Bath, for valuable services rendered in connexion with Military Operations in France and
Flanders, dated June 3, 1918.

To be Additional Members of the Military Division of the Third Class, or Companions of the
said Most Honourable Order : —

Temp. Major-Gen. Sir Anthony Alfred Bowlby, K.C.M.G., Iv.C.V.O., F.R.C.S., Army Medical
Service.

Temp. Major-Gen. Cuthbert Sidney Wallace, C.M.G., Army Medical Service.
Lieut.-Col. and Brevet-Col. (Temp. Col.) Thomas Wykes Gibbard, M.B., K.H.S., Army
Medical Service.

Col. Stuart Macdonald, C.M.G., M.B., Army Medical Service.

Lieut.-Col. and Brevet-Col. Allan James Macnab, F.R.C.S. , Indian Medical Service.
Col. Edgar Montague Pilcher, D.S.O.. M.B., F.E.C.S., Army Medical Service.
Col. George St. Clair Thorn, C.M.G., M.B., .4.rmy Medical Service.

Canadian Force.

Col. Arthur Edward Rose, C.M.G., Canadian Army Medical Corps.

Chanceey of the Ordeb of Saint Michael and Saint George.

Downing Street,

June .3, 1918.

The King has been graciously pleased, on the occasion of His Majesty's Birthday, to give
directions for the following promotions and appointments to the Most Distinguished Order of
Saint Michael and Saint George, for services rendered in connexion with military operations in
France and Flanders, dated June 3, 1918.

To be Additional Members of the Second Class, or Knights Commanders, of the said Most
Distinguished Order : —

Surg.-Gen. Menus William O'Keefe, C.B., M.D.

Col. Sir William Boog Leishman, Kt., C.B., F.R.S., M.B., F.R.C.P., K.H.P.

To be Additional Members of the Third Class, or Companions, of the said Most Distinguished
Order : —

Temp. Col. Owen William Richards, D.S.O., M.D., F.R.C.S., L.R.C.P., Royal Army Medical
Corps,

Col. Wilfred Edward Hudleston, D.S.O., Army Medical Service.

Col. Robert William Clements, D.S.O., M.B.

Lieut.-Col. (Temp. Col.) Edward Maudsley Morphew, D.S.O., Royal Army Medical Corps.

Lieut.-Col. Thomas Arthur Granger, M.B., Indian Medical Service.

Lieut.-Col. (Temp. Col.) Harold Collinson, D.S.O., M.B. , F.R.C.S., Royal Army Medical Corps.

Lieut.-Col. (Temp. Col.) Albert George Thompson, D.S.O., M.B., Royal Army Medical Corps.

Lieut.-Col. (Temp. Col.) James Stuart Gallie, D.S.O., Army Medical Service.

Lieut.-Col. William Richard Blackwell, Royal Army Medical Corps.

Major and Brevet Lieut.-Col. Eugene Ryan, D.S.O., Royal Army Medical Corps.

Lieut.-Col. (Temp. Col.) James Andrew Hartigan, D.S.O., M.B., Royal Army Medical Corps.

Lieut.-Col. Albert Ernest Hamerton, D.S.O., Royal Army Medical Corps.

Major and Temp. Col. Henry Mcllree Williamson Gray, C.B., M.B., F.R.C.S., Royal Army
Medical Corps.

Major (Temp. Lieut.-Col.) William Lawrence Steele, Royal Army Medical Corps.

Temp, and Hon. Major Charles George Jarvis, L.R.C.P., Royal Army Medical Corps.

Major Maurice Sinclair, M.B., Royal Army Medical Corps.

Major (Temp. Lieut.-Col.) Edmund Thurlow Potts, D.S.O., ^I.D., Royal Army Medical Corps.

Canadian Force.

Col. John Munro Elder, Canadian Army Medical Corps.

Australian Force.
Col. Robert Beveridge Huxtable, D.S.O., V.D., Army Medical Corps.

War Office,

June 3, 1918.
His Majesty the. King has been graciously pleased, on the occasion of His Majesty's Birthday,
to approve of the undermentioned rewards for distinguished service in connexion with military
operations in France and Flanders, dated June 8, 1918 :—

To BE Brevet-Colonel.
(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in the
case of Officers belonging to these categories, as applicable.)

Lieut.-Col. (Temp. Col.) G. J. A. Ormsby, D.S.O. , M.D., Royal Airmy Medical Corps.

To be Brevet Lieutenant-Colonel.
(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in
the case of Officers belonging to these categories, as applicable.)

Major (Temp. Lieut.-Col.) E. B. Bird, D.S.O., Roval Army Medical Corps.

Major (Acting Lieut.-Col.) C. G. Browne, D.S.O., Royal Army Medical Corps.

Major (Acting Lieut.-Col.) P. Davidson, C.M.G., D.S.O., M.B., Royal Army Medical Corps.

Major (Acting Lieut.-Col.) C. H. Turner, D.S.O., Royal Army Medical Corps.

To BE Brevet-Major.
(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in
the case of Officers belonging to these categories, as applicable.)

Capt. L. G. Bourdillon, D.S.O., M.C., Royal Army Medical Corps.

To BE Honorary Major.
Qmr. and Hon. Capt. J, W. Osborne, Royal Army Medical Corps.

To BE GRANTED THE NEXT HiGHEK RaTE OF PaY UNDEB THE PbOVISIONS OF THE ROVAI.

Warrant.
Temp. Qmr. and Hon. Capt. C. A. Kay, Royal Army Medical Corps.

\ Awarded a Bab to the Distinguished Service Order.
Capt. (Temp. Lieut.-Col.) Arthur Thomas Pitts, D.S.O., Royal Army Medical Corps.

.Awarded the Distinguished Service Order.
Royal Army Medical Corps.

Major Thomas Ashley Barron.

Capt. (Acting Lieut.-Col.) William Blackwood,

M.B.
Capt. (Acting Lieut.-Col.) Colin Clarke, M.B.,

F.R.C.S.
Temp. Capt. James Alphonsus Conway, M.C. ,

M.D.
Capt. Ernest Marshall Cowell, M.B., F.R.C.S.
Capt. (Temp. Liout.-Col.) Francis William

Murray Cunningham, M.D.
Temp. Capt. (Acting Lieut.-Col.) Ralph Evelyn

Drake -Brockman.
Lieut.-Col. William Edward Foggie, M.D.
Capt. and Brevet-Major (Acting Lieut-Col.)

Claude Howard Stanly Franknau, M.B.,

F.R.C.S.
Temp. Capt. Samuel Sowray Greaves, M.C.
Major (Temp. Lieut.-Col.) Richard Collis

Hallowes, M.B.
Capt. (Acting Lieut.-Col.) Robert Hemphill.
Temp. Capt. (Acting Lieut.-Col.) Albert Jones,

Major (Acting Lieut. -Col.) Rowland Philip

Lewis.
Major (Temp. Col.) Creighton Hutchinson

Lindsay, C.M.G.
Capt. Ambrose Lome Lockwood, M.C.
Capt. (Acting Lieut.-Col.) Arthur Norman Roy

McNeill.
Capt. (Acting Lieut.-Col.) Sinclair Miller, M.C.
Temp. Hon. Capt. Humphrey Nockolds.
Lieut.-Col. John Powell, M.B.
Major Alan Charles Turner.
Capt. (Acting Lieut.-Col.) Ernest Wentworth

Wade, M.B.
Major Douglas Percival Watson, j\r.B.
Capt. (Acting Lieut.-Col.) Alfred John

Williamson.

Major (Temp. Lieut.-Col.) Ernest Charles
Hodgson, Indian Medical Service.

Major Ernest Albert Churchward Matthews,
Indian Medical Service.

M.C.

Canadian Force.
Army Medical Corps.

Lieut.-Col. George Joseph Boyce. | Lieut.-Col. John Nisbet Gunn.

Lieut.-Col. Auson Scott Donaldson. Lieut.-Col. Joseph Hayes.

Major George Herbert Rae Gibson. | Lieut.-Col. Daniel Paul Kappele.

Lieut.-Col. Archibald Lome Campbell Gildav, Major Theodore Adolf Lomer.
M.C.

Australian Force.
Army Medical Corjys.

Lieut.-Col. Balcombe Quick.
Lieut.-Col. (Temp. Col.)

Shepherd.
Major Walter Jaques Stack.
Major Wilfred Vickers.

Arthur Edmund

Major Francis Lawrence Bignell.
Lieut.-Col. Edward Thomas Brenan, M.C.
Major Arthur Ross Clayton.
Capt. Slervyn John Holmes.
Lieut.-Col. William Elphinstone Kay.
Major Donald Stuart Mackenzie.
Lieut.-Col. (Temp. Col.) Frederick Arthur
Maguire.

New Zealand Force.
Major Erick Arthur Widdowson, M.C.

South African Contingent.
Major Charles jMolteno Murray, M.C.

Awarded a Bar to the Military Cross.
*Capt. Thomas Stokoe Elliot, M.C, Royal Army Medical Corps.

Capt. Arthur Edmund Ironside, M.C, Royal Army Medical Corps (M.C. gazetted June 24, 1916).
*Temp. Capt. George William Blomfield James, M.C, Royal Army Medical Corps.
*Capt. Hamilton Stephen Moore, M.C, M.B., Royal Army Medical Corps.
Capt. (Acting Major) Hugh Huntley Robinson, M.C, Royal Army Medical Corps (M.C.
gazetted November 14, 1916).

*Capt. John Rowe, M.C, M.B., Royal Army Medical Corps.

* Note. — In the cases marked by an asterisk the announcements of awards of the Military
-Cross have not yet been published in the London Gazette. These awards will be published in
due course.

Awarded the
Royal Army
Temp. Capt. Wilfred Herbert Alderton.
Temp. Capt. Eobert Harper Alexander, M.B.
Capt. Robert Pringle Anderson, M.B.
Temp. Qmr. and Hon. Lieut. George Samuel

Annett.
Temp. Capt. Geoffrey Thomas Baker.
Capt. Richard Pitt Ballard, M.B., Special

Reserve.
Temp. Capt. Stanley Ba'tchelor.
Temp. Capt. William David Bathgate.
No. .34731 Serjt. -Major Alfred Bolland.
Temp. Capt. William Brownlie, M.B.
Temp. Capt. Charles Walter Gordon Bryan.
Capt. Alexander Carruthers Bryson, M.B.
Capt. Frederick Charles Chandler, M B.
Temp. Capt. Bloomfield George Henry

Connolly, M.B.
No. 45555 Serjt. -Major Leslie Alfred Cronk. .
Capt. David Dempster, M.B.
Capt. James Derham-Reid.
Temp. Capt. John Wescott Dew, M.B.
Capt. George Sampson EUiston.
Temp. Capt. Keith Douglas Falconer, M.B.
Temp. Capt. Richard Desmond Fitzgerald, M.B.
Qmr. and Hon. Capt. Charles Frederick Fraser.
Temp. Capt. Hope Murray Gillsie, M.B.
Capt. Charles Norman Grover, M.B., Special

Reserve.
Temp. Capt. Ranald Montague Handfield-

Jones.
Capt. Nicholas Hopkins Henry Haskins, iLB.
Capt. Sidney Martin Hattersley, M.B.
Temp. Capt. John Berry Haycraft, M.B.
Temp. Capt. Godfrey John Douglas Hindley,

M.B.
Temp. Capt. Austin Harvey Huycke. M.D.
Capt. David William John, Special Reserve.
Temp. Capt. Joseph Greenfield Johnston, M.B.
• Capt. Griffiths Lewis Jones, Special Reserve.
Tamp. Capt. David Anderson Duncan Kennedv,

M.B.

Canadian Force.
Capt. (Acting Major) William Theodore Ewing, Army Medical Corps.

Australian Imperial Force.
Army Medical Corps.
Capt. Roy Douglas Bartram. I Capt. Cedric Murray Samson.

Capt. Ivan Bede Jose. | Capt. John Alexander Shanasy.

Capt. Norman Reginald Mathews. j

New Zealand Force.
Capt. Philip Blaxland Benham, New Zealand Medical Corps.

Awarded the Distinguished Conduct Medal.
Royal Army Medical Corps.

Military Cross.
Medical Corps.

Lieut. (Acting Capt.) Gerald Patrick Kidd,

Special Reserve.
Temp. Capt. Francis James Lidderdale, M.B.
No. 11370 Serjt. -Major Frederick Loveland.
Capt. Donald Christopher MacDonald, M.B.,

Special Reserve.
Temp. Capt. William James MacDonald, M.B.
Temp. Capt. John Beattie MacFarland.
Temp. Capt. Donald Maclntyre, M.B.
Capt. William George McKenzie.
Capt. William Farquhar McLean, M.B.,

Special Reserve.
Capt. Henry Proce Malcolm, M.B.
Capt. Francis Robery Henry Millan, Special

Reserve.
No. 2653 Serjt. -Major Frederick Charles

Morrison.
Temp. Capt. Cusack O'Malley, M.B.
Temp. Capt. Herbert IMassingberd Pentreath.
Capt. George Loraine Kerr Pringle, M.D.
Capt. Albert Ramsbottom, jM.D.
Temp. Capt. Ralph Stuart Renton, M.D.
Capt. Douglas George Rice-Oxley.
No. 38683 Serjt-Major John Given Richardson.
Temp. Capt. Robert Stuart Ross.
Temp. Capt. William James Rutherford. M.D.
Qmr. and Hon. Lieut. George Sellex.
Capt. Clement Perronet Sells.
Capt. John James Macintosh Shaw, M.B.
Capt. Edward Swan Simpson, M.B.
Capt. George Henderson Stevenson, M.B.,

Special Reserve.
Capt. Francis Geoffrey Thatcher, M.B.
Temp. Capt. John Hardwick Thornley, M.B.
Temp. Capt. James Arnaud Tobin, M.B.
Capt. William McNiell Walker, Special Reserve.
Temp. Capt. John Watson, M.B.
Temp. Cap{. Alexander Urquhart Webster,

M.B.

No. 3910188 Serjt. A. Green (Hull).

No. 352080 Serjt. R. Lomax (Nelson).

No. 17091 Qmr. Serjt. (Acting Serjt.-Major)

J. Moore (Edinburgh).
No. 1417 Pte. (Acting Lance-Cpl.), C. Smith

(Winchester).

No. 536001 Qmr. Serjt. (Temp. Serjt.-Major)

H. E. Bevans (St. John's, S.E.).
No. 354259 Pte. E. C. Bowkett (Manchester).
No. 303003 Staff-Serjt. (Acting Qmr. Serjt.)

J. Brown (Aberdeen).
No. 55195 Serjt. D. Charleson (Leith).
No. 354100 Serjt. H. E. Dowling (Manchester),

Chancery of the Order of Saint Michael and Saint George.

y Downing Street,

June 3, 1918.
The Kiug has been graciously pleased, on the occasion of His Majesty's Birthday, to give
directions for the following appointment to the Most Distinguished Order of Saint Michael and
Saint George, for services rendered in connexion with Military Operations in Italy. Dated
June 3, 1918 :—

To be Additional Member of the Third (lass or Companion of the said Most Distinguished

^' Maj7r (Acting Lieut. -Col.) George Herbert Leonard Hammcrton, D.S.O., Royal Army Medical

Corps.

Awarded the Distinguished Service Order.

Lieut. -Col. William Chapman Croly. Royal Army Medical Corps. ,t„^ „oi

Capt (Temp. Major, Acting Lieut.-Col.) Thomas Arthur Green, M.D., Royal Army Medical

^° Temp. ('apt. Wilfred John Pearson, M.C., M.B., Royal Army Medical Corps.

Awarded the Military Cross.
Royal Army Medical Corps.
Temp. Capt. Francis John Allen, M.B. ' I Temp. ('apt. Eric Alfred Lumley. M.B.

Tern? Capt. Lawrence Weir Bain. M.B. 1 Temp. Capt. Michael Patrick I'ower.

TcmS Capt.William Edward Hallinan. t Capt. Ludwig Siebert Benjamin Tasker M.B.

No 17229 Serjt. -Major William Hutchens. | No. 12UG Serjt.-Major William John Wilson.

His Majesty the King has been graciously pleased, on the occasion of His Majesty's J^'irUiday,
to annrove of the award of the Meritorious Service Medal to the undermentioned Wari-ant Officers,
Non commissioned Officers and Men in recognition of valuable services rendered with the forces

"^ * ^ ■ RoYAii Army Medical Corps.

No. 18678 Qmr.-Serjt. (Temp. Serjt.-Major)

No. 2007 Cpl. A. F. Morrell (Fulham).

No. 66577 Serjt. S. A. Peyton (Reading).

No. 36427 Pte. (Acting Serjt.) W. H. Pointon

(Featherstoue).
No. 33255 Serjt. W. A. Robertson (Glasgow).
No. 435017 Qmr.-Serjt. A. H. Stenip (Little

Bromwich).
No. 90906 Staff-Serjt. (Acting Qmr.-Serjt.)

F. W. Ct, Waghorne (Wembly).

L. S. Ellis (Brighton). . . ^r tt

No. 35048 Serjt. (Acting Qmr.-Serjt.) H. H.

Hards (London, N.W.).
No. 58965 Pte. (Acting Qmr.-Serjt.) D. A.
Hart (London. E.). . ,^ . .

No. 40178 Staf! -Serjt. (Acting Serjt. -Major)

W. Henser (Stoke).
No. 30629 Staff-Serjt. (Acting Serjt.-Major) G.
Martin (Broadstairs).

Cestral Chancery of the Orders of Knighthood.

St. James's Palace, S.W.
June 3, 1918.
His Maiestv the King has been graciously pleased, on the occasion of His Majesty's Birthday,
to g^ve Orders for the following appointments to the Most Honourable Order o the Bath for
valuable services rendered in connexion with Military Operations in Egypt, dated June 3, 1918

To be Additional Members of the Military Division of the Third Class or (, ompanions of the
said Most Honourable Order : —

Col. Alfred Conquer Keeble, CM. G., D.S.O. ^r ^- i n

Temp. Lieut.-Col. James William Barrett, C.M.G., Royal Army Medical Corps.

Chancery op the Order op Saint Michael and Saint George.

Downing Street,

Jime 3, 1918.
His Majesty the King has been graciously pleased, on the occasion of His Majesty's Birthday, to
give d'recUons for the following appointment to the Most Distmguished Order of Saint Michael
fnd SaTnt George, for services rendered in connexion with Military Operations m Egypt, dated

"^'"'ro^e Additional Member of the Third Class or Companion of the said Most Distinguished

Order * —

Col' Daniel O'SuUivan.F.R.C.S.L, Army Medical Service.

War Office,

June 3, 1918.
His Majesty the King has been graciously pleased on the occasion of His Majesty's Birthday
to approve of the undermentioned rewards for distinguished service in connexion with Military
Operations in Egypt.

To be Brevet Lieutenant-Colonel.

(On Retired List, Reserve of Officers, Special Reserve, New Army, or Territorial Force, in the
case of Officers belonging to these categories, as applicable).
Major H. V. Bagshawe, D.S.O., Royal Army Medical Corps.
Major C. A. Gill, Indian Medical Service.

To be granted Next Higher Rate op Pay.
Qmr. and Hon. Lieut. C. F. Houston, M.C., Royal Army Medical Corps.

AWABDED THE DISTINGUISHED SERVICE OEDER.

Capt. (Acting Lieut.-Col.) Herbert William Carson, M.B., Royal Army Medical Corps.
Capt. (Acting Lieut.-Col.) John Wilson Leitch, M.B., Royal Army Medical Corps.
Capt. (Acting Lieut.-Col.) Thomas Bramley Layton, M.D. , Royal Army Medical Corps.
Capt. Oakar Teichmann, M.C, Royal Army Medical Corps.
Lieut.-Col. Hugh Wright Thomson, M.D., Royal Army Medical Corps.

Australian Force.
Lieut.-Col. Arthur Lacy Dawson, Army Medical Corps.

New Zealand Force.

Major Charles Hercus, Medical Corps.

Awarded the Military Cross.

Capt. Douglas Wales Berry, M.D., Royal Army Medical Corps.

Capt. Humphrey Francis Humphreys, M.B., Royal Army Medical Corps.

Capt. Cyril Eaton Petley, Royal Army Medical Corps.

His Majesty the Kiug.has been graciously pleased, on the occasion of His Majesty's Birthday,
to approve of the undermentioned rewards for distinguished service in connexion with the British
Forces in Egypt : —

Awarded the Distinguished Conduct Medal.

No. 546124 Cpl. (Acting Coy. Serjt.-Major) L. T. Leybourne, Royal Army Medical Corps
(Cambridge).

No. 32251 Serjt.-Major G. F. Lyon, Royal Army Medical Corps (Norwich).

No. 12496 StaS-Serjt. (Acting Serjt.-Major) J. McKay, Royal Army Medical Corps (Aberdeen).

His Majesty the King has been graciously pleased, on the occasion of His Majesty's Birthday,
"to approve of the award of the Meritorious Service Medal to the undermentioned Warrant
Officers, Non-commissioned Officers and Man in recognition of valuable services rendered with
the Force in Egypt : —

No. 545778 Pte. (Acting Serjt.) H. J. Garrett, Royal Army Medical Corps (Bristol).

No. 56188 Serjt. D. Gibson, Royal Army Medical Corps (Stamford Hill).

No. 60270 Serjt. (Acting Staff-Serjt.) A. E. Waight, Royal Army Medical Corps (Croydon).

No. 17057 Qmr. -Serjt. (Acting Serjt.-Major) M. Ward, Royal Army Medical Corps (Belfast).

War Office,

June 11, 1918.
The following Dispatch has been received by the Secretary of State for War from Lieut.-Gen.
G. F. Milne, K.C.B., D.S.O., Commander-in-Chief, British Salonika Force: —

General Headquarters, Salonika,

March 25, 1918,
My Lord, — I have the honour to submit herewith a list of the names of the Officers, Warrant
Officers, Non-commissioned Officers, Men and Nursing Staff, whose services I desire to bring
to your Lordship's notice for gallant conduct and distinguished services rendered during the
period from September 21, 1917, to February 28, 1918.

I have the honour to be. My Lord,

Your Lordship's most obedient servant,

G. F. Milne, Lieut.-Gen.
Staff.

Lieut.-Col. P. H. Henderson, D.S.O., M.B., Royal Army Medical Cerps.
Col. (Temp. Major-Gen.) M. P. C. Holt, K.C.M.G., C.B., D.S.O.
Col. G. T. Rawusley, C.M.G.

Royal Army Medical Corps.

Temp. Capt. D. I. Anderson, M.B. I Temp. Capt. J. H. McNicol, M.C, M.B.

Temp. Capt. G. V. Bakewell, M.B. | Temp. Capt. F. H. Morrell, Special List.

Temp. Capt. D. M. Borland, M.B. Capt. (Acting Major) A. L. Urquhart, M.B.

Temp. Capt. R. C. Brown, M.B. ! Temp. Lieut.-Col. C. M. Wenyou, C.M.G., M.B.

Temp. Capt. P. C. Davie, M.B. '■ Temp. Capt. E. C. White, M.B.

Capt. E. Davies, M.B. '] Major R. K. White.

Temp. Lieut. E. Gardner, M.B. ; Temp. Capt. A. Wilkin.

Major (Acting Lieut.-Col.) F. J. Garland, M.B. | Temp. Major H. W. Wiltshire.

Temp. Capt. T. E. George, M.B. j No. 55375 Cpl. E. Aitken.

Capt. and Brevet-Major (Acting Lieut.-Col.) No. 17169 Cpl. (Acting Lance-Serjt.) W.

B. Johnson, M.B. . Andrews.

Lieut.-Col. M. M. Lowsley. No. 148 Serjt. (Acting Staff-Serjt.) J. Ashcroft.

Temp. Capt. L. G. McCune, M.B. ! No. J05942 Pte (Acting Serjt.) A. Ashton.

Capt. A. M. McCutcheon, M.B. ' No. 56211 Cpl. (Acting Serjt.) F. Baldwin.

No. 24217 Pte. F. Barlow.

No. 80541 StaffSerjt. G. T. Berry.

No. 53341 Pto. J. R. Brierly.

No. 69383 Pte. (Acting Cpl.) G. C. Channon.

No. 18627 StatT-Serjt. B. Coekburn.

No. 40957 Staff-Serjt. (Actiug Qmr.-Serjt.)

F. J. Copeland.
No. 58578 StaffSerjt. (Acting Qmr.-Serjt.)

A. Darby.
No. 1216 Pte. (Acting Cpl.) J. Dunne.
No. 50357 Cpl. (Acting Lance-Serjt.) L.

Dunstall.
No. 24154 Pte. H. R. Edwards.
No. 66975 Pte (Acting Serjt.) A. Engleby.
No. 59675 Serjt. T. Fletcber.
No. 79349 Cpl. (Acting Serjt.) H. H. Frankham.
No. 54527 Pte (Acting Lance-Cpl.) T. Froud.
No. 51445 Pte. H. J. Havnes.
No. 21340 Pte. (Actiug Lance-Serjt.) R.

Henderson.
No. 7246 Pte. (Acting Cpl.) T. Hickey.
No. 25810 Staff-Serjt. B. Hill.
No. 61840 Pte. G. W. Howell.
No. 75167 Pte. J. Inman.

No. 110318 Pte. (Acting Cpl.) 0. E. Lloyd-
Jones.
No. 23530 Qmr.-Serjt. A. Keen.
No. 78644 Serjt. (Acting Serjt. -Major) E. W.

King.
No. 56640 Pte. (Actiug Lance-Cpl.) J. A.

Kiulev.
No. 57433 Pte. K. E. Lightfoot.

No. 0367 Pte. (Acting Lance-Cpl.) J. E. Luff.
No. 3630G Cpl. (Acting Lance-Serjt.) J. P.

Manuion.
No. 11211 Qmr.-Serjt. (Temp. Serjt Major)

L. T. Marsden.
No. 6251 Serjt. (Actiug Serjt.-Major) P. J.

Martin.
No. 60081 Serjt. (Acting Staff-Serjt.) A. R.

Miles.
No. 924.33 Pte. R. Morri.s.
No. 75027 Serjt. A. Newton.
No. 70983 Serjt. J. O'Brien.
No. 39261 Cpl. (Acting Serjt.) H. Palk.
No. 31047 Pte. (Actiug Lance Cpl.) H. Parsons.
No. 68310 Pte. (Actiug Cpl.) R. Paterson.
No. 60049 Pte. (Acting Serjt.) J. D. Perritt.
No. 52025 Pte. (Actiug Cpl.) A. Redhead.
No. 30337 Pte. M. Ritchie.
No. 47032 Pte. F. H. Roberts.
No. 40719 Serjt. M. V. Sargent.
No. 1578 Acting Serjt. E. Savage.
No. 61753 Pte. (Acting Cpl.) W. Saxe.
No. 18957 Staff-Serjt. (Acting Company-Qmr.-

Serjt.) A. C. Smith.
No. 21033 Pte. L. Spivey.
No. 79455 Pte. (Acting Cpl.) W. Stewart.
No. 68971 Pte. (Acting Lance-Serjt.) J.

Straw.
No. 81787 Pte. R. C. Williams.
No. 19453 Staff-Serjt. A. C. Wingate.
No. 65533 Pte. R. A. Wood.
No. 1616 Cpl. (Actiug Serjt.) H. C. Yates.

Royal Army Medical Corps (Special Reserve).

Capt. T. Y, Barkley, M.B.
Capt. M. C. Cooper.
Capt. G. G. Drummond.

Capt. J. A. Musgrave,
Capt. H. B. Sherlock, M.C.
Capt. H. M. Torrance, M.B.

Royal Army Medical Corps (Territorial Force).

Capt. (Temp. Major) A. W. Falconer, D.S.O.,

M.B.
Capt. C. E. C. Ferrey.
Qmr. and Hon. Capt. G. W. Harris.
Capt. D. A. Harwood.

Capt. (Temp. Lieut.-Col.) H. G. G. I\Lackenzie.
Capt. W. H. Manson.
Capt. B. E. Potter.
Capt. P. S. Price.

Major and Brevet Lieut.-Col. F. E. A. Webb.
Lieut.-Col. J. R. Whait, M.B.
Capt. G. White.
Capt. H. W. Weir.
No. 493180 Serjt. A. G. Brace.
No. 527604 Staff-Serjt. T. F. Button.
No. 366128 Cpl. (Acting Lance-Serjt.) W. G.

Charles.
No. 536145 Serjt. J. D. Clark.
No. 388130 Pte. T. W. Craigill.
No. 403018 Serjt. H. Duncan.

No. 497208 Serjt. A. Ford.

No. 493277 Pte. (Ackiug Lance-Cpl.) H. C. G.

Geary.
No. 527057 Staff-Serjt. C. A. Grabham.
No. 527312 Lance-Cpl. C. S. Hasemer.
No. 495035 Pte. D. H. Hughes.
No. 510109 Pte. (Actiug Lance-Cpl.) E. M

Jones.
No. 495594 Pte. V. W. Jov.
No. 587167 Cpl. (Acting Serjt.) F. H. Leather.

dale.
No. 497186 Cpl.' G. J. Lilly.
No. 510051 Pte. L. C. Maeers.
No. 336329 Pte. C. Prescott.
No. 546627 Cpl. (Acting Lance-Serjt.) J. R-

Rogers.
No. 545547 Staff-Serjt. W. H. Scott.
No. 388190 Pte. W. F. Thwaites.
No. 216018 Staff-Serjt. F. Underbill.
No. 528058 Pte. (Acting Serjt.) W. R. Wilkins.

MiSCELLANEODS LiST.

Ramsbottom, Esq., attached Royal Army Medical Corps.

War Office,

June 14, 1918.
The following dispatch has been received by the Secretary of State for War from General Sir
H. H. Allenby, G.C.M.G., K.C.B., General Officer Commanding-in-Chief, Egyptian Expe-

ditionary Force :-

General Headquarters,

Egyptian Expeditionary Force.

April 3, 1918.
My Lord,— I have the honour to forward herewith a list of Officers, Ladies, Non commissioned
Officers and Men, serving, or who have served, under my command, whose distinguished and
gallant services and devotion to duty I consider deserving of special mention.

I have the honour to be, my Lord,

Your Lordship's most obedient servant,

E. H. H. Allenby, General. .
Staff.
Capt. F. W. C. Brown, M.B., Royal Army Medical Corps.
Col. G. T. K. Maurice, C.M.G., Army Medical Service.
Lieut.-Col. (Temp. Col.) E. P. SeweU, D.S.O., M.B., Royal Army Medical Corps.

Army Medical Service and Royal Army Medical Corps.

Temp. Lieut.-Col. J. W. Barrett, C.M.G.

Capt. (Acting Lieut.-Col.) H. W. Carson, M.B.

Lieut. (Temp. Capt.) E. Catford.

Qmr. and Hon. Capt. T. E. Coggon.

Major (Acting Lieut.-Col.) W. P. Ellis.

Lieut.-Col. W. P. Gwynn.

Temp. Capt. L. Leslie.

Temp. Capt. The Hon. L. H. Lindley, M.B.

Temp. Capt. T. F. Lumb.

Temp. Capt. (Acting Lieut.-Col.) A. T. Mulhall,

F.R.C.S.I.
Temp. Capt. P. W. Moore. M.B.
Col. D. O'Sullivan, F.R.C.S.I.
Capt. (Acting Lieut.-Col.) G. F. Budkin, D.S.O.
Capt. W. H. Sheffield, M.B.
Temp. Capt. E. B. Smith, M.D.
Temp. Lieut. H. G. Sparrow.
Capt. (Acting Major) W. W. Treves, M.B.,

F.R.C.S.
Temp. Capt. J. G. Willmore.
No. 57267 Pte. (Acting Serjt.) F. H. Andrews.
No. 473207 Cpl. G. S. Briggs.

No. 18490 Staff-Serjt. (Acting Qmr.-Serjt.) H.

Cooper.
No. 69398 Pte. C. Daly.

No. 22038 Pte. (Acting Serjt.) W. Darlington.
No. 63378 Pte. (Acting Serjt.) G. Fairclough.
No. 36115 Serjt. (Acting Staff-Serjt.) G. H.

Hornby.
No. 25S69 Qmr.-Serjt. (Acting Serjt. -Major)

C. J. Judd.
No. 6803 Pte. W. Lee.

No. 33569 Serjt. (Acting Qmr.-Serjt.) W. Meeds
No. 32945 Serjt. F. C. Mitchell.
No. 51671 Pte. (Acting Serjt.) H. J. Rowlands.
No. 26666 StafT-Serjt. T. M. Sayer.
No. 19110 Serjt. (Acting Staf!-Serjt.) C. H.

Smith.
No. 16047 Qmr.-Serjt. (Temp. Serjt. -Major) P.

Springett.
No. 1509 Serjt. A. Warren.
No. 1825 Serjt. (Acting Qmr.-Serjt.) A. G.

Williams.

Royal Army Medical Corps (T.F.).

Capt. C. H. Allen, M.B., F.R.C.S.

Capt. C. S. P. Black, M.C., M.B.

Capt. (Temp. Major) T. G. Buchanan, M.B.

Capt. C. H. Budd, M.C., M.B.

Capt. W. K. Churchouse.

Capt. H. N. McC. Coombs, M.B..

Capt. W. F. Corfield, M.D.

Capt. A. D. Downes, M.B.

Capt. (Temp. Major) H. J. Dunbar.

Lieut.-Col. T. H. Forrest, D.S.O., M.B.

Lieut. .Col. A. G. Hamilton.

Capt. W. T. Henderson, M.B.

Temp. Capt. C. W. Jenner.

Capt. (Acting Lieut.-Col.) T. B. Layton, M.D.

Major (Acting Lieut.-Col.) J. W. Leitch, M.B.

Capt. E. A. Mackenzie

Capt. G. R. Rickett, M.D.

Capt. A. P. B. Smith.

Capt. J. B. Stanley.

Capt. 0. Teichmann, M.C.

Lieut.-Col. H. H. Thomson, M.D.

Capt. F. Ward, M.D.

Capt. G. H. H. Way leu.

Capt. G. A. Williamson, M.D.

Capt. K. B. Williamson.

Capt. (Temp. Lieut.-Col.) J. Young, M.B..

F.R.C.S.
No. 315086 Cpl. (Acting Serjt.) D. M.

Alexander.
No. 416051 Cpl. (Acting Serjt.) H. Andrews.
No. 67947 Stafi-Serjt. H. E. Eden.
No. 475165 Lance-Cpl. W. Harris.
No. 545446 Lance-Cpl. (Acting Serjt.) F.

Hartley.
No. 533018 Serjt. H. S. Hiles.
No. 544796 Serjt. (Acting Serjt.) C. J. Legg.
No. 318004 Qmr.-Serjt. (Acting Serjt. -Major)

W. Millar.
No. 320138 Serjt. W. Murray.
No. 362078 Serjt. W. Pritchard.
No. 303016 Qmr.-Serjt. (Acting Serjt. -Major)

C. C. Thom.
No. 316087 Staff-Serjt. W. Thompson.
No. 472003 Serjt. V. J. Tootell.
No. 311064 Lance-Serjt. (Acting Serjt.) A. M. D.

Wright.

War Office,

Jum 22, 1918.
His Majesty the King has been graciously pleased to approve of the following Awards to the
undermentioned Officers and Warrant Officers, in recognition of their gallantry and devotion to
dutv in the Field : —

Awarded the Distinguished Service Order.

Capt. (Acting Lieut. -Col.) Robert Bernard Price, M.B., Itoyal Army IMcdical Corps.

For conspicuous gallantry and devotion to duty. Prior to the division going into action be
took over tbe duties of Assistant Director of ^Icdical Services at balf an hour's notice. When
on one occasion all casualty clearing stations in the neighbourhood of the division were with-
drawn, his improvisation on tbe previous night of an emergency casualty clearing station
further to the roar proved of such inestimable value, that a large number of casualties were able
to bo dealt with and all the wounded evacuated with the utmost dispatch. Owing to the
recourse, forethought and exceptional powers of organization, tbe smooth and successful
evacuation of all the wounded was carried out during the period of twelve days' heavy and
continuous fighting in which the division was engaged.

Awarded a Bar to the Military Cross.

Capt. John Henry Pearson Fraser, M.C., M.B., Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. During the evacuation of a town lie was
in charge of a train loaded with stores and equipment. While the train was standing in the
station without an engine it was heavily bombed by enemy aeroplanes. With bombs falling all
round ho secured an engine which bad just backed into the station and coupled it to the train.
He then collected a few men and cleared the permanent way of masses of debris caused by the
bombs, and eventually got the train safely away under continual bombing by enemy aeroplanes.
By his courage, determination and resource in a most difficult situation he succeeded in saving
the whole trainload of equipment. (M.C. gazetted February 4, 1918.)

Temp. Capt. Frederick Theophilus Hill, M.C, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. Several hundred casualties of all branches
of the service were passed through his unit during the day, and were evacuated promptly,
thanks to his zeal, enei-gy and efficient organization. When the enemy were advancing his unit
was the last to leave the neighbourhood, and finally withdrew, when ordered to do so, and
when every case had been evacuated, to join the division. He displayed outstanding devotion
to duty. (M.C. gazetted June 23, 1915.)

Capt. (Acting Major) Herbert Stewart Milne, M.C, M.D., Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty, when in charge of an advanced dressing
station. In spite of continuous shelling he dressed and superintended the evacuation of the
wounded during three days' operations with great success. When a shell fell among a party of
men, killing three and wounding fourteen of them, he succeeded in dressing the more severely
wounded and getting them all removed to a place of safety before the next burst of fire fell in
the same spot. By his courage and resource he undoubtedly saved a further loss of life. (M.C.
gazetted June 3, 1918.)

Temp. Capt. Matthew Arnold Swan, M.C, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. When the majority of his stretcher
bearers had become casualties and his advance post had received two direct hits from shells he
stayed at his post, dressed the wounded and supervised their evacuation. On many other
occasions he showed the greatest courage, coolness and initiative, and his conduct has at all
times been exemplary. (M.C. gazetted June 3, 1916.)

Awarded the Military Cross.

Temp. Capt. Warren Fullerton Clark, M.B., Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. Whilst the battery was being heavily
shelled two men were badly wounded. He at once proceeded out into the open, attended to
these men under the most intense shell fire, carried them into a trench, and remained with
them until an ambulance arrived. He showed magnificent coolness and an utter disregard of
danger.

Temp. Capt. John Norman Cruickshank, M.B., Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. He attended to the wounded under heavy
fire during an enemy attack. His skilful organization of stretcher bearers and his coolness and
determination in a most difficult situation resulted in the saving of many lives.

Capt. John Francis Hill, M.B., Royal Army Medical Corps (Special Reserve).

For conspicuous gallantry and devotion to duty. He worked throughout the day under
incessant shell fire, attending to tbe wounded during an enemy attack. Owing to his coolness
and skill in a most difficult situation, many lives 'were saved.

Temp. Capt. Andrew Ferguson Horn, M.B., Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. He led his bearers forward to the front
line during a heavy enemy attack and brought back many severely wounded men through tbe
enemy's barrage. Throughout the operations he displayed splendid coolness and courage under
heavy fire.

Qmr. and Hon. Capt. Robert Daniel Matthews, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. On hearing that two Sisters were lying
injured on the adjacent railway station, he took over dressings and' attended to them and other
wounded while a hostile bombing raid was in progress. He brought back all the wounded to
the hospital, and later worked continuously in a bumiug ammunition train at great risk from
exploding shells, attending to the wounded and arranging for their comfort. His gallantry and
coolness were deserving of the highest praise.

No. 16216 Serjt. -Major John William Robinson, Royal Army Medical Corps.

For conspicuous gallantry and devotion to duty. Throughout two days he worked unceasingly,
organizing and directing parties of stretcher bearers, visiting the advanced aid posts and
supervising the work of the advanced dressing station, which was continuously shelled. Later,
his marked organizing ability was made use of in the establishment of a new divisional collecting
station to meet the emergency created by the absence of any clearing station within a short
distance, and, thanks to his skill, resource and untiring energy, several hundred wounded cases
were very rapidly evacuated in comparative comfort. His courage, endurance and devotion to
duty during a period of ten days' fighting have been an inspiration to all ranks.

The following is the correct description of an Officer upon whom a Reward has recently been
conferred : —

Temp. Capt. Alfred James Ireland, M.C., M.B., Royal Army Medical Corps. (M.C. gazetted
August 25, 1917.)

War Office,

June 17, 1918.
■ His Majesty the King has been graciously pleased to approve of the award of the ^leritorious
Service Medal to the undermentioned Warrant Officers, Non-commissioned Officers and Men, in
recognition of valuable services rendered with the Forces in France during the present war : —

Royal Army Medical Corps.

No. '42694 Pte. (Acting Cpl.) G. H. Adams

(Dartmouth).
No. 545186 Pte. (Acting Serjt.) J. P. Addison

(Brandon Colliery).
No. 26.361 Cpl. (Acting Serjt.) G. E. Adey

(Ashby-de-la-Zouch).
No. 50222 Pte. (Acting Serjt.) F.Alden(Nor\vich).
No. 32268 Qmr. -Serjt. T. W. Allcard (Grimsby).
No. 32048 Serjt. -Major A. N. Appleby (Leeds).
No. 48754 Staff-Serjt. (Acting •Qmr."'-Serjt.) E.

Barmby (Preston).
No. 417296 Acting Serjt. C. F. Beck (Derby).
No. 508269 Serjt. A. E. Bennett(London, S.E.).
No. 545494 Serjt. J. Birnie (Birkenhead).
No. 60088 Pte. (Acting Serjt.) J. J. Blackie

(Duns).
No. 401249 Serjt. T. Blakebrough (Leeds).
No. 473180 Qmr.-Serjt. G. Blows (Cherry-

hinton).
No. 30589 Staff-Serjt. P. G. Boxall (Chudleigh).
No. 527369 Serjt. J. Briden (Walthamstow).
No. 48322 Serjt. (Acting Qmr.-Serjt.) E. J.

Brown (Coleford).
No. 17151 Serjt. (Acting Qmr.-Serjt.) J. T.

Brown (E. London).
No. 42914 Pte. (Acting Serjt.) W. J. Bunting

(Belfast).
No. 34922 Qmr.-Serjt. A. W. Burden (London,

S.W.).
No. 538086 Qmr.-Serjt. (Temp. Serjt. -Major)

F. L. Burrows (W. Newington).
No. 50328 Serjt. J. H. Campbell (Waterhouse,

Co. Durham).
No. 40941 Pte. S. Campbell (Belfast). '

No. 45731 Serjt. -Major W. Campbell (Dunferm-
line).
No. 32187 Staff-Serjt. (Acting Serjt.-Major)

H. V. Cattlev (Whitby).
No. 527301 Serjt. H. A. G. Chandler (Hasle-

mere).

No. 46033 Staff-Serjt. C. H. Chastou (Leigh

on-Sea).
No. 49426 Qmr.-Serjt. T. W. Clark (Sunderland).
No. 58999 Serjt. (Staff-Qmr.-Serjt.) H. Clarke

(Sutton Bridge, Lines.).
No. 2221 Serjt. (Acting Stafi-Serjt.) G. Coleman

(Wynberg, S. Africa).
No. 26552 Pte. S. Collins (Rhondda).
No. 352187 Pte. R. Cooper (Burnley).
No. 403556 Cpl. (Acting Serjt.) A. Cox (Mj th-

olmrovd).
No. 16092 Cpl. (Acting Serjt.) C. Crowe (Mary-

borough (Queen's Countv).
No. 50971 Staff-Serjt. j! Dale (Woodhouse,

near Sheffield).
No. 437003 Staff-Serjt. (Acting Serjt.-Major)

A. H. Dancer (Sutton Coldfield).
No. 405019 Pte. P. Dent (Sheffield).
No. 403082 Qmr.-Serjt. A. M. Dewhurst (Ship-
ley).
No. 337443 Pte. T. H. Dinsdale, M.M. (Walton).
No. 1862 Serjt. (Acting Staff-Serjt.) G. A. Doyle

(Omagh).
No. 1188 Pte. (Acting Cpl.) M. Doyle (Dublin).
No. 417228 Qmr. Serjt. A. R. Ellis (Luton).
No. 527244 Pte. (Acting Serjt.) W. A. Ellis

(Stamford Hill).
No. 545075 Serjt. E. Ellison (Essington).
No. 17450 Staff-Serjt. (Acting Qmr. Serjt.)

W. J. Elsev (Pembroke Dock).
No. 19039 Serjt. (Acting Qmr.-Serjt.) J. T.

Emerson (Cosham).
No. 56602 Staff-Serjt. (Acting Qmr.-Serjt.) E.

Evans (Sunderland).
No. 536333 Qmr.-Serjt. I. Fisher (Wood Green).
No. 1464 Serjt. (Acting Qmr.-Serjt.) J. Fitz-
gerald (Aldershot).
No. 619S5 Cpl. (Acting Lance-Serjt.) R. J.

Fitzgibbons (Kennington Cross, S.E.).
No. 49093 Serjt. J. Fooks (Watchet. Somerset).

No. 49-45 Serjt. (Acting Staff-Serjt.) J. E.

Fornian ((E). Aldershot).
No. 40655 Scrjt. -Major H. J. C. Frowin (Ruislip).
No. 18507 Stad-Serjt. (Actiug Qmr. -Serjt.) W.

A. Gerrio (.Mdershot).
No. 49521G Serjt. R. J. Giles (Folkestone).
No. 14452 Serjt. (Acting StaffSerjt.) F. Godfrey

(Edinburgh).
No. 514001 Qmr.-Serjt. (Temp. Serjt. -Major)

W. R. Gillett (Clapham, S.W).
No. 341279 Cpl. (Acting Serjt.) A. D. Goulding

(St. Helens).
No. 73745 Pte. (Acting Cpl.) A. W. Grattidge

(Leicester).
No. 545673 Pte. (Acting Serjt.) D. Gray

(Carlisle).
No. 8GS96 Cpl. (Acting Serjt.) G. B. Green

(Eastbourne).
No. 5168 Serjt. (Acting Qmr.-Serjt.) H. Gregory

(Manchester).
No. 49332-2 Serjt. G. Gurnev (Gillingham).
No. 59489 Serjt. -Major C. G.'Gwynn (Hastings).
No. 45612 Serjt. J. C. Hagger (New Barnet).
No. 37849 Pte. (Acting Serjt.) D. Hall (Oldham).'
No. 20478 Staff-Serjt. J. W. Hastings, D.C.M.

(Manchester).
No. 395019 Serjt. A. Hedlev (Newcastle-on-

Tvne).
No." 72241 Serjt. -Major F. G. Herbert

(Leicester).
No. 72152 Serjt. (Acting Qmr.-Serjt.) F. H.

Herbert (Bromlev, Kent).
No. 17250 Serjt. (Acting Staff-Serjt.) A. Hobbs

(Guildford).
No. 47316 Serjt. (Acting Staff-Serjt.) P. G.

Hollo way (Bath).
No. 512250 Qmr.-Serjt. E. A. Hopkins (Har-

ringay).
No. 58454 Staff-Serjt. (Acting Serjt. -Major) F.

M. Hudson (South Shields).
No. 341291 Serjt. W. A. Hunter (St. Helens).'
No. 17576 Qmr.-Serjt. (Acting Serjt. -Major) J.

R. Ireson (Southminster).
No. 30623 Scrjt. -Major .J. R. Ivins (Chelsea,

S.W.).
No. 534004 Staff-Serjt. W. James (Erith, Kent).
No. 38805 Serjt. (Acting Staff-Serjt.) E. C.

Jeeves (Blunham).
No. 66321 Serjt. -Major F. W. Jeffries (Ring-

wood).
No. 19471 Cpl. (Acting Serjt.) D. C. Johnston

(Bridge of Dunn).
No. 39536 Qmr.-Serjt. W. H. Jones (Barry

Dock, Glam.).
No. 30624 Qmr.-Serit. J. Judd, (Brixton, S.W.).
No. 339004 Lance-S'erjt. J. Kay (Liverpool).
No. 4924 Pte. (Acting Cpl.) A. B. Kelly (Trimm,

Co. Meath).
No. 13S14 Qmr.-Serjt. (Acting Serjt. -]Major) P.

Kenneallv (Castlemartyr).
No. 13032 Qmr.-Serjt. T. Kerr (Ballymena).
No. 19268 Cpl. (Acting Staff-Serjt.) J. B.

Kersey (St. Leonards-ou-Sea).
No. 345009 Serjt. (Acting Serjt. -Major) N. F.

Kirkwood (Liverpool).
No. 73691 Pte. (Acting Cpl.) R. W. Kirtley

(South Shields).
No. 55230 Cpl. (Acting Serjt.) W. J. Lawrence

(Balham, S.W.).

No. 16442 Staff-Serjt. (Acting Qmr.-Serjt.) W.

Lawson (Dublin).
No. 339483 Serjt. J. S. Leigh (Blackpool).'
No. 2257 Serjt. T. J. Lever (Wolverhampton).
No. 527613 Staff-Serjt. (Acting Serjt.-Major)

J. S. Liudloy (Batley, Yorks).
No. 457372 Pte. (Acting Lance-Cpl.) R. Luxton

(Exeter).
No. 16678 Qmr.-Serjt. (Acting Serjt.-Major)

J. E. March (Leicester).
No. 60984 Serjt. J. G. Mark (Castle Eden,

Durham).
No. 350168 Pte. J. B. Marsden (Glossop).
No. 18632 Pte. (Acting Serjt.) F. Martin

(Gravesend).
No. 49848 Pte. (Acting Lance-Cpl.) G. Martin

(Dublin).
No. 457240 Staff-Serjt. (Acting Qmr.-Serjt.) S.

Martin (Torpoint).
No. 5808 Cpl. (Acting Staff-Serjt.) M, M. D.

Maxwell (Worcester).
No. 14850 Staff-Serjt. (Acting Qmr.-Serjt.)

T. G. Mayman (Southsea).
No. 4962G Pte. C. ]\IcConkey (Li/erpool).
No. 12155 Serjt.-Major A. McKay (Aberdeen).
No. 3525S Qmr.-Serjt. D. McKechnie, ]\LM.

(Dundee).
No. 59373 Serjt. W. ISIellor (Manchester).
No. 125.37 Qmr.-Serjt. (Temp. Serjt.-Major) F.

Mollov (Cork).
No. 41200 Staff-Serjt. G. Morrell (Leeds).
No. 459420 Pte. E. W. Mumford (Lelant).
No. 19605 Cpl. (Acting Qmr.-Serjt.) M. Nairn

(Colchester).
No. 403837 Serjt. W. Naylor (Knaresborough).
No. 510211 Serjt. E. E. Nott (Catford, S.E. 6).
No. 417221 Serjt. J. L. Cakes (Derby).
No. 15721 Serjt.-Major A. E. Odell (Lough-
borough).
No. 56588 Pte. W. O'Hare (Clough, Co. Down).
No. 386009 Qmr.-Serjt. (Acting Staff-Serjt.) H.

Ord (Gosforth, Newcastle-on-Tvue).
No. 18213 Staff-Serjt. W. C. Pacev (Bordon).
No. 463003 Qmr.-Serjt. L. Parkhouse (Exeter).
No. 18718 Qmr.-Serjt. (Temp. Serjt.-Major)

W. H. Parr (Lee, Kent).
No. 341430 Qmr.-Serjt. (Temp. Serjt.-Major)

R. R. Parry (Liverpool).
No. 459002 Qmr.-Serjt. (Temp. Serjt.-Major)

T. W. Parsons (Chudleigh, S. Devon).
No. 2225 Cpl. M. Paterson (York).
No. 32424 Pte. (Acting Cpl.) R. V. Peake

(Southsea).
No. 65795 Sierjt. A. C. Piper (Hailsham).
No. 17421 Serjt. P. Plume (Bury St. Edmunds).
No. 15095 Serjt.-Major J. E. Pugh (Shrews-
bury).
No. 34410 Qmr.-Serjt. A. H. Purser (Cowes).
No. 61620 Staff-Serjt. H. Race (Bradford,

Yorks).
No. 310022 Staff-Serjt. F. Rae (Aberdeen).
No, 37249 Serjt. J. Rattray (Perth).
No. 461029 Pte. (Acting Serjt.) A. Reed (South-
ampton).
No. 85911 Pte. (Acting Serjt.) J. F. Riggs

(Pimlico, S.W.).
No. 33404 Cpl. S. T. Roberts (Liverpool).
No. 35954 Serjt.-Major D. C. S. Robertson

(West Hartlepool).

No. 50101 Pte. (Acting Serjt.) A. W. Robinson
(St. Ives),

No. 106920 Pte. R. Rooke (Boughton, near
Faversham).

No. 39472 Staff-Serjt. (Acting Qmr.-Serjt.) A. V.
Rowe (Middlewick).

No. 6125 Cpl. (Acting Serjt. A. J. Sage (E.
Waterford).

No, 19933 StafE-Serjt. (Acting Qmr. Serjt.)
W. C. Savegar (Aldershot).

No. 341411 Qmr.-Serjt. (Temp. Serjt. -Major)
F. C. Scrutton (Penketh).

No. 47208 Serjt. J. A. Sharpley (Sunbury-on-
Thames).

No. 527541 Staff-Serjt. G. W. Shipley (Marske-
bv-Sea).

No."'l2411 Staff-Serjt. (Acting Qmr.-Serjt.) A. A.
Sims (Reading).

No. 44847 Pte. (Acting Cpl.) H. Slee (Leeds).

No. 78018 Serjt. (Acting Qmr.-Serjt.) H. S.
Smitb (]\Iexborough).

No. 37373 Qmr,-Serjt. G. R. Spragg (Chelten-
ham).

No. 303053 Qmr.-Serjt. J. Stables (Kennsth-'
mont).

No. 38707 Serjt.-Major W. B. Stedman (Mar-
gate).

No. 17568 Serjt.-Major E. Steele (Surbiton).

No. 43087 Serjt. J. P. Stephen (Inverallochy).

No. 44817 Cpl. G. H. Stewart (Paisley).

No. 39086 Staff-Serjt. T. Stinton (Manchester).

No. 301010 Qmr. Serjt. C. P. Stuart (Torvie).

No. 11801 Cpl. (Acting Staff-Serjt.) J. Sturges
(Oxford).

No. 49938 Qmr.-Serjt. N. Sumner (Warrington).

No. 4682 Serjt. A. E. Taylor ((E) .\ldershot).

No. 42273 Serjt. W. Taylor (Bridlington).

No. 435317 Qmr.-Serjt. W. H. Taylor (Birming-
ham).

No. 545447 Pte. (Acting Lance-Serjt.) J. Top-
ping (Carlisle).

June 26, 1918.
His Majesty the King has been pleased to award the Distinguished Conduct Medal to the
undermentioned for Gallantry and Distinguished Service in the Field : —

No. 1828 Pte. M. Connolly, Royal Army Medical Corps (Dublin).

For conspicuous gallantry and devotion to duty. On an advanced aid post being subjected
to a prolonged bombardment, during which period two direct hits from enemy shells were
registered on it, he stayed at his post, and wherever casualties occurred he went out to bring in
the wounded, rescuing six men in such a manner. Throughout this period he afforded magnifi-
cent proof of utter contempt for danger and outstanding devotion to duty.

No. 493540 Pte. R. B. McCoy, Royal Army Medical Corps (Maidstone).

For conspicuous gallantry and devotion to duty when the aerodrome of the squadron to
which he was attached was attacked by enemy aircraft. He was badly wounded in the thigh
by the first bomb that fell, and though he could only walk with great difficulty, he struggled
towards the other casualties and attended to them while bombs were still dropping and the
enemy aeroplanes were attacking the aerodrome with machine-gun fire. His splendid courage
and self-sacrifice saved the life of a man who would have died had he not been attended to
immediately.

June 27,. 1918.

His ]\Iajesty the King has been graciously pleased to approve of the award of a Bar to the
Military Medal to the undermentioned : —

No. 223 Serjt. (Acting Staff-Serjt.) W. Peake.M.M., Royal Army Medical Corps (Layerthorpe).
(M.M. gazetted April 10, 1918.)

His Majesty the King has been graciously pleased to approve of the award of the Militarj'
Medal to the undermentioned Non-commissioned Officers and Men : —

No. 301241 Staff-Serjt. (Acting Qmr.-Serjt.)

L. G. Tough (Aberdeen).
No. 35693 Serjt. (Acting Staff-Serjt.) W, J.

Twidell (Luton).
No. 527140 Staff-Serjt. I. I. Ungar (Listria

Park, N.).
No. 12790 Cpl. (Acting-Serjt.) L. P. Unwin

(Thornton Heath).
No. 34259 Staff-Serjt. W. Uden (Catford, S.E.).
No. 5880 Cpl. (Acting Qmr.-Serjt.) W. C. Val-

lance (Dublin).
No. 49962 Staff-Serjt. (Acting Qmr.-Serjt.) P.

Walmsley (Brooke's Bar).
No. 18126 Serjt. (Acting Qmr.-Serjt.) T. P.

Walshe (Rochester).
No. 18621 Staff-Serjt. (Acting Serjt.-Major) A. J.

Walton (Birmingham).
No. 67281 Serjt. W. P. Waterhouse (Levens-

hulme).
No. 11320 Serjt.-Major R. Watts (Upper Toot-
ing)-
No. 493320 Qmr.-Serjt. (Temp. Serjt.-Major)

W. W. Weedon (Maidstone).
No. 18821 Staff-Serjt. (Acting Serjt.-Major)

G. Weston (Rochester).
No. 82197 Serjt.-Major J. S. Witham (Burnley).
No. 405420 Cpl. (Acting Serjt.) H. Wilde (Brad-
ford).
No. 31747 Serjt.-Major G.M. Wilshaw(Burnley),
No. 401417 Staff-Serjt. A. E. Wood (Leeds).
No. 71796 Pte. E. F. Wood (Denholme).
No. 527854 Staff-Serjt. (Acting Serjt.-Major)

F. H. Wood (Bromley).
No. 4356 Serjt. R. Woodman (Shepherd's Bush).
No. 5442 Serjt. (Acting Qmr.-Serjt.) A. E.

Woodward (Stonehouse).
No. 15022 Staff-Serjt. (Acting Serjt.-Major) F.

Woodward, D.C.M. (E. Swindon).
No. 64046 Serjt. D. Yates (Norton Malton).

•21

Royal Army Medical Corps.

No. 10G789 Pte. W. Ashton (Blackburn).
No. 42G012 Serjt. G. W. Boalcr (Leicester).
No. 19311 Ptc. (Acting Cpl.) H. J. Cantello

(Liiveudcr Hill).
No. 3-2017 Pte. :M. H. Choctham (Sydenham).
No. 40527 Ptc. (Acting Lance-Cpl.) J. Clarke

(Middlcwich).
No. 70508 Pte. W. Cox (Sheffield).
No. 315092 Pte. (Acting Lance-Cpl.) A, E.

Dickson (Glasgow).
No. 493G05 Pte. J. B. F. Duffett (Maidstone).
No. 495390Pte. S. T. Edinborough (Folkestone).
No. 7227 Pte. (Acting Cpl.) J. Finn (Sheffield).
No. 61631 Pte. J. W. Gallagher (Dublin).
No. 44420 Pte. G. Glover (Hindley).
No. 6305 Cpl. (Acting Serjt.) A. W. Goswell

(Folkestone).

No. 31557 Ptc. W. H. Gotts (E. Bury St.

Edmunds).
No. 31561 Pte. A. Green (Forest Hill).
No. 7491 Pte. C. T. Hartley (Blctchley).
No. 43543 Pte. P. L. Jarrctt (Maidstone).
No. 493397 Pte. (Acting Cpl.) A. Larkia

(Speldhurst).
No. 352589 Pte. W. Lawson (Manchester).
No. 73581 Pte. W. Leslie (Glasgow).
No. 31386 Pte. J. McPherson (Edinburgh).
No. 495335 Pte. H. A. \V. Rainer (Folkestone).
No. 8881 Pte. J. Scholefield (Shipley).
No. 32668 Cpl. L. E. Smith (Sheffield).
No. 9024 Pte. E. Walton (Leeholme).
No. 59458 Pte. K. White (Tooting).
No. 12185 Staff-Serjt. (Acting Qmr.-Serjt.)

A. S. Willis (Harringay).

KOYAL AEMY MEDICAL CORPS FUND.

Proceedings of a Committee meeting held at the Royal Army Medical College, Grosvenor
Road, on Monday, June 10, 1918, at 2 p.m., the Director- General, Armv Medical Service
(Lieut-Gen. T. H. J. C. Goodwin, C.B., C.M.G., D.S.O., K.H.S.), presiding.

Present.

Major-Gen. G. B. Stanistreet, C.B., C.M.G., D.D.G., A.M.S.

Major-Geu. Sir W. Donovan, K.C.B.

Surg.Gen. Sir D. Bruce, K.C.B.

Col. Sir J. Magill, K.C.B.

Lieut-Col. A. B. Cottell.

Major E. P. Offord.

(1) The minutes of the last meeting were read and confirmed.

(2) The question as to whether the education of children shall be undertaken by the General
Relief Branch when the Compassionate School Fund is exhausted was considered, and it was
decided to recommend to the Annual General INIeeting that the principle should be approved,
subject of course to the financial condition of the Fund at any time.

(3) The draft of proposed book of rules as recommended by the sub-committee was considered
and adopted with certain minor amendments, and it was decided to recommend to the Annual
General Meeting that it shall be adopted and printed at a cost not exceeding £10.

(4) The report of the memorials sub-committee was received, and after discussion it was
decided to recommend to the Annual General Meeting —

(i) That a suitable memorial with portrait medallions of officers who were mainly concerned
in the movement that led to the unification of the Army Medical Department and to the
formation of the R.A.M.C. be erected in the Royal Army Medical College at a cost not exceeding
^500.

(ii) That a special portrait of Lieut.-Gen. Sir A. Keogh, wearing the Insignia of the Grand
Cross of the Bath, should be painted, and

(iii) That a portrait of Lieut.-Gen. Sir A. Sloggett, K.C.B., K.C.M.G., K.C.V.O., K.H.S.,
should be added to the gallery of Director-Generals in the mess room.

(5) Two applications for assistance from the General Relief Branch were considefi'ed and
grants approved. In the case of one where there is a possibility of the pension being increased
the amount not to exceed £1 a mouth up to a maximum of £6.

The sixteenth Annual General Meeting of the Royal Army Medical Corps Fund was held in
the library of the Royal Army Medical College on Monday, June 10, 1918, the Director-General
(Lieut-Gen. T. H. J. C. Goodwin C.B., C.M.G., D.S.O., K.H.S.) presiding.

(1) The report of the Committee was read and adopted as follows : —

(i) The number of annual subscribers has diminished from 984 in 1916 to 824 in 1917; a
considerable number of the young officers who were granted permanent commissions last year
have joined in response to a circular letter which was sent out in August, and no doubt others
will subscribe at the termination of the war. The Fund has sustained heavy losses by death.

(ii) The accounts of the Fund have been separated into two branches, viz,,, Officers' Branch
for band dinner and memorials, and General Relief Branch, which includes the small amount
still remaining which was originally allocated specially for the education of children.

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(iii) Officers Branch. — Tho income amounted to £1,267 16s., and as the expenditure continues
to be small owing to tho War, £850 has been invested in War Loan, 1915, 5 per cent., making :i
total now held by tho branch in that security of £2,300.

(iv) Dinner. —There was no dinner last year and no expenditure on memorials.

(V) Band. — .\ grant of £100 has been made to the band.

(vi) General Relief Brandt. — Grants and subscriptions to the amount of £1,494 10s. 2d. were
received from companies and units abroad and as the applications for assistance were few in
numl)er a further sum of .^1,100 has been invested in War Loan 5 per cent and National War
Bonds. The annual subscriptions to the Union Jack Club and other societies are met by this
branch.

(vii) Compassionate School Fzmrf.— Grants have been made to the Royal Soldiers' Daughters'
Home at Hampstead, the Drummond Institute in Ireland and the Catholic Home for Destitute
Children, at each of which we have children being educated, and the sum of £198 remains. This
will be sufficient to complete the education of the children now at school.

(viii) The Committee record with deep regret the death of Lieut. -Col. F. W. H. Davie
Harris who had been secretary of the Society for more tlian eleven years and to whose
unfailing efforts in the interests of the Fund much of its success is undoubtedly due.

(2) The accounts for the year 1917 which have been audited were considered and approved.
A copy is attached to the Proceedings.

(3) The question of voting a grant from the Officers Branch to the General Relief Fund was
discussed, and it was proposed by Col. C. R. Tyrrell, and seconded by Lieut. -Gen. A. T. Sloggett,
that a sum of £25 be authorized. Carried.

(4) The principle as to whether the education of children shall be undertaken by the
General Relief Branch when the sum of money still remaining in the Compassionate School
Fund is exhausted was discussed. It was explained by the secretary that this Fund originated
in a sum of nearly £1,400 subscribed by No. 6 General Hospital during the South African War
and limited at the request of Col. Somerville Large, who was then in command, to the
education of children. This amount is nearly exhausted and it is a question whetiier when it
has been expended the education of children will subsequently be taken over by the General
Relief Fund. After discussion it was proposed by Gen. Sir W. Donovan and seconded by
Gen. Sir M. Russell, and carried, that the principle be approved that the education of children
shall be taken over by the General Relief Fund when the sum belonging to the Compassionate
School Fund is exhausted, subject to the financial position of the Fund at any future time.

(5) The proposed book of rules which has been circulated was approved with certain minor
alterations to be adopted and printed, the cost not to exceed £10.

(6) Memorials. — The recommendation of the Committee as regards memorials to distinguishaiA
officers was considered and adopted as follows : —

(i) That a suitable memorial with portrait medallions of officers who were mainly concerned
in the movement that led to the unification of the Army Medical Department and to the
formation of the Royal Army Medical Corps be erected in the Royal Army Medical College at a
cost not exceeding £500.

(ii) That a special portrait of Lieut. -Gen. Sir A. Keogh, wearing the Insignia of the Grand
Cross of the Bath, should be painted, and

(iii) That a portrait of Lieut.-Gen. Sir A. Sloggett, K.C.B., K.C.M.G., K.C.V.O,, K.H.S.,
should be added to the Gallery of Director-Generals in the mess room.

As regards the portraits, as there is at the present time great uncertainty as to the cost, the
Committee are requested to furnish a further report before the matter is finally sanctioned.

(7) Auditors. — It was proposed by Sir D. Bruce and seconded by Sir W. Donovan that Messrs.
Evans, Peirson and Co. be reappointed for the present year.

(8) A letter was read from Mr. V. G. M. Holt recommending that the £1,000 6 per cent.
Exchequer Bonds, 1920, standing in the names of the trustees on account of the General Relief
Branch should he sold and the proceeds invested in 5 per cent National War Bonds, 1928, and
tho. difference resulting from the transaction added to the present holding of the Fund. It was
" ilesolved that Messrs. Holt and Co. be instructed to sell £1,000 6 per cent. Exchequer Bonds,
1920, held on account of the General Relief Fund, and to take up £1,200 5 per cent. National
War Bonds, 1928, to be invested in the names of the trustees. Also that the Director-General
be authorized to sign the Resolution on behalf of the Fund."

(9) The secretary' reported that a sum of £28 13s. 6d. had been received as a Rebate of
Income Tax for the General Relief Branch for the year 1917.

Secretary. — Proposed by Sir Launcelotte Gubbins and seconded by Sir A. Sloggett that
Lieut. -Col. Wilson be elected secretary for one year. Carried.

E. M. Wilson,

Lieut. -Col., Secretary.

IMiNCTES OF A Committee Meeting held at Adastral House, War Office,

ON July 17, 1918.

Present :
Lieut.-Geu. T. H. J. C. Goodwin, C.B., C.M.G., D.S.O., K.H.S.,

Director General, in the Chair.
Major-Gen. G. B. Stani street, C.B., C.M.G., Deputy Director-General.
Major-Gen. Sir W. Donovan, K.C.B.
Col. C. R. Tyrrell, C.B.
Lieut.-Col. A. B. Cottell.
Major-P. G. Easton, D.S.O.
Major E. P. Oflord.

(1) The minutes of the previous meeting, held on June 10, were read and confirmed.

(2) The Secretary reported the printing of 600 copies of the new book of Rules which are being
distributed to the subscribers.

' (3) The Report of the Memorials Sub-Committee was considered and it was decided : —

(}) As regards the ^lemorials to certain distinguished officers who were mainly concerned in
the unification of the Army Medical Department and the formation of the Royal Army
!Medical Corps that before inaking a final selection notification should be sent to :
(a) All Surgeon-Generals and JMajor-Generals, past and present, and
\b} All officers who were on the active list between 1870 and 1880, giving the names
of officers provisionally proposed and asking for suggestions. The replies to
be considered at the next meeting,
(ii) The offer of Mr. F. 0. Salisbury to paint the portrait of Lieut. -Gen. Sir A. T. Sloggett

was approved. The total inclusive charge not to exceed the amount agreed upon,
(iii) It was noted that the Memorials Sub-Committee are in communication with Sir
A. Keogh.

(4) The Secretary submitted a Report of the meeting of the " Comrades of the Great War"
Association on July 4, and it was decided that no actioil is necessary at present.

(5) A case of special distress under Rule 5 was considered and it was decided to sanction a
monthly grant of .C5 as a temporary measure pending the result of an appeal for an increase of
pension which is now being dealt with by the financial authorities.

(6) The Secretary reported the sale of £1,1 00 6 per cent Exchequer Bonds and the purchase
of .1:1,200 5 per cent National War Bonds which had been carried out on behalf "of the General
Relief Branch in accordance with the Resolution of the Annual General Meeting. He also
reported the present cash balances in both bivinches of the Fund.

(7) An application for assistance from the widow of an ex-Stafi-Serjeant under Rule 8 was
considered and a grant of £6 authorized.

ROYAL ARxMY MEDICAL CORPS OFFICERS'
BENEVOLENT SOCIETY.

The Aunual General ^Meeting was held at the Library, Royal Army Medical College,
Grovesnor Road, S.W., at .3 p.m. on Monday, June 10, 1918, the Director:General, Army
Medical Service (Lieut. -General T. H. J. C. Goodwin, C.B., CM. G., D.S.O. , K.H.S.), presiding.

(1) The Minutes of the last Annual General Meeting were read and confirmed.

(2) The report of the Committee for the j'ear 1917 was considered and adopted as follows : —
The number of subscribers for the year was 181 and the amount of subscriptions £1S4 18s. 6d.
A sum of £196 7s. 6d. has been received as a rebate of Income Tax and is credited in the

accounts for the year 1918.

Donations were received from : —

Officers' Mess Training Centre, Ripon . .

Lieut.-Col. and Mrs. Brunskill ..

Royal Army ]\Iedical Corps Officers' Mess, Rawal Pindi

Surg. -Gen. and Mrs. Julian

An Anonymous Friend, per Major T. H. Gibbon. .

A Legacy under the Will of the late Surg. -Gen. Sir Charles Cuffe

The total receipts amounted to £646 7s. 2d.

The £200 Exchequer Bonds purchased in 1916 have been converted into :g200 5 per cent War
Loan and ah additional amount purchased bringing up the total holding of the Society in that
Security to .£450.

The total expenditure amounted to £785 3s. The office expenses for 1917 are being charged
to the accounts of the year 1918, and will amount to £62 Is. 8d.

Thirty-one applicants representing fifty-eight orphans were granted £755.

The Committee record with deep regret the death of Lieut.-Col. Davie Harris, who had been
secretary of the Society for more than ejeven years, and to whose unfailing efforts in the interests
of the Fund much of its success is undoubtedly due.

£20

(3) Tho audited accounts for the year 1917 were received and approved. A copy is attached
to these Proceedings. 4

(4) The grants to applicants recommended by the Committee for the year were considered
and approved. Two other applications which had heon received since the Committee meeting
were considered and grants authorized. In a third case the application was refused. The
amounts voted together with tho initials of tlie applicants are attached.

(5) Tho Secretary reported that nearly (iOO special notices had been sent out with a view to
increasing the number of subscribers, and up to the present time forty-seven additional officers
had joined the Society. .

(6) Tho resignation of Col. J. L. Notter as Vice-President was accepted with regret, and it
was proposed by Major(ien. Sir W. Donovan and seconded by Col. Peterkin that Surg. -Gen. Sir
Michael Russell bo elected Vice-President. Carried. The other Vice-Presidents were re-elected.

(7) It was proposed bv the Chair and seconded by Sir Launcelotte Gubbins that Surg.-(ien.
Sir H. R. Whitehead be elected a member of the Committee. Carried. And that the remainder
of the Committee be reelected. Carried.

(8) Auditors.— 'V\\& Auditors, Messrs. Evans, Peirson and Co., were re- elected Auditors.

(9) Lieut. -Col. E. M. Wilson was re-elected Secretary for one year from the present date.

(10) It was proposed by Sir A. Sloggett and seconded by Sir Launcelotte Gubbins that a very
hearty vote of thanks be accorded to the Director-General for presiding at both meetings.

Carried. ^ . ^ ,

E. M. Wilson, Lieut. -Colwiel,
Secretary.

Minutes of a Committke Meeting held at Adastral House, War Office, ok

July 17, 1918.

Present :
Lieut.-Gen. T. H. J. C. Goodwin, C.B., C.M.G., D.S.O., K.H.S., Director-General, in the
Chair.

Major-Gen. Sir W. Donovan, K.C.B.

Surg. -Gen. Sir D. Bruce, K.C.B.

Surg. -Gen. Sir H. R. Whitehead, K.C.B.

Major-Gen. Sir M. W. Russell, K.C.M.G.

Col. A. Peterkin, C.B.

Lieut. -Col. A. B. Cottell.

Capt. J. T. Clapham.

(1) The minutes of the previous meeting, held on April 17, were read and confirmed.

(2) Sir M. W. Russell and Sir H. R. Whitehead took their places on the Committee as Vice-
President and member respectively.

(3) The Secretary repotted that 102 fresh subscribers had been obtained up to date as a
result of the special appeal for additional members. He also reported the present cash balance

at the bank. -.1 .r.^

(4) A special appeal was considered from Mrs. L. INI. T. for a grant towards the outfit
expenses of her daughter who has just been elected to the Royal School at Bath, and it was
decided to sapctiou £20 under Rule 24. , r 1 o .l 1

(5) The desirability of making it more widely known that the Funds of the Society are only
available for the benefit of " orphans " was discussed, and the Secretary was instructed to draw-
attention to the fact in all notices issued from his office.

LIST OF GRANTS AUTHORIZED TO APPLICANTS AT THE ANNUAL GENERAL

MEETING, JUNE 10, 1918.

Orphan of J. 0. . . . . £30

Three orphans of T. McC. . . £40

Three orphans of G. C. . . 40

Orphan son of P. 0. 1. . . . . 10

Orphan daughter of I. McC. . . 20

Two orphan daughters of V. H. S. 20

Four orphan daughters of W. S. H. 40

Orphan daughter of T. S. . . 10

Orphan daughter of I. C. . . 25

Two orphans of F. M. M. . . 20

Orphan of R. A. C. . . . . 40

Seven orphans of J. W. . . 30

Orphan son of C. A. . . . . 30

Orphan of J. F. . . • • 30

Orphan of A. S. . . • . 20

Three orphans of W. T. H. . . 30

Orphan son of R. G. H. . . 20

Two orphans of R. D. O'C. . . 20

Orphan of W. F. T. I. . . 40

Orphan of H. P. E. . . . . 10

Orphan of T. B. . . . . 40

Orphan of A. T. . . . . 30

Two orphans of C. J. H. . . 20

Orphan of E. W. B. . . .. 30

Orphan of B. C. S. . . . . 20

Seven orphans of W. H. . . 40

Orphan of H. H. S. .. .. 2-5

£730

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AKMY MEDICAL OFFICERS' WIDOWS AND ORPHANS

FUND.

Summary op the Proceedings op the OneHundred and Third Annual General Meeting,

WHICH WAS held AT THE RoYAL ARMY MeDICAL COLLEGE ON MaY 13, 1918.

Present :
Deputy Surg.-Oeu. W. G. Dou, Vice-President, in the Chair.
Surg.-Gen. Sir H. R. Whitehead, K.C.B.
Surg. -Gen. Sir M. W. Russell, K.C.M.G., C.B.
Major-Geu. J. J. Gernird, C.B.
Col. W. T. Martin.

Col. Sir W. B. Leishman, K.C.M.G., C.B., F.R.S., K.H.P.
' Lieut. -Col. J. Stevenson (a Trustee).

Lieut. -Col J. More Reid.
Lieut.-Col. G. S. Mansfield.
Letters regretting their inability to attend were read from Surg.-Gen. W. S. ^I. Price, and
from Lieut.-Col. P. S. O'Reilly.

(1) The Minutes of the previous Annual General Meeting were read and confirmed.

(2) The Accounts and Report for the year 1917 were examined and adopted unanimously.

(3) Messrs. Deloitte and Co. were re appointed Auditors for the cutrent year.

(4) The election by the Committee, under Rule XXVI, of Surg.-Gen. Sir H. R. Whitehead,
K.C.B. , as a member thereof in place of Lieut.-Col. R. J. L. Fayle, D.S.O. , resigned, was
confirmed.

Major-Gen J. J. Gerrard, C.B., was elected a member of the Committee for the coming three
years in the place of Col. Sir W. H. Horrocks, K.C.M.G., C.B., who retires at the expiration of
his peyod of office.

The Meeting expressed much regret at the death of the late Mr. H. W. Andras, F.I. A., Con-
sulting Actuary to the Society. (A resolution of condolence had been already sent by the Com-
mittee to his widow.)

Sir Michael Russell advocated the reduction, or abolition, of the present extra War charge.
Under the Rules the Committe must be guided in this matter by the advice of the -Actuary.

NOTICE.
This Fund provides annuities of £50 a year during widowhood, to the widow of the marriage,
during which the subscription of a married member began. In the event of the death of the
widow this annuity is continued to the children of such marriage until the youngest attain the
age of 21 years. It also continues for their benefit, up to the same age, if the widow re-marries.
Furthermore, should the wife of the subscriber predecease him, it will be optional for him to
continue the subscription he had been paying as a married member, in order to provide an
annuity similar to the above for the children of the marriage, until the youngest shall have
attained the age of 21 years.

Provision is also made whereby a part of the surplus at any quinquennial valuation may be
applied for the benefit of members, or their wives, or orphan children. Thus, by the appropria-
tions of surplus at the valuations of December 31, 1910 and 1915, the prospective widows of first-
class married members on the books at those dates, will receive, during this current quin-
quennium, £200 and £100 respectively at the death of their husbands, their annuities being also
increased to the statutory limit of £52.

Examples of the rates of annual subscription are : —

Husband's W'ife's Annual

age age .-iiibscription

25 .. 20 .. £13 8 5

30 .. 27 .. £14 6 1

36 .. 33 .. £16 17 2

46 .. 40 .. £22 12 6

50 .. 45 ,. £24 9 5

The present extra War charge, which is subject to revision, is 25 guineas per^annjim, in
addition to the normal annual subscription according to scale. OnlV Regular officers are eligible
for membership.

Unmarried officers may become members by paying £2 yearly, and can thus reduce the rate
of their subscriptions when married.

The Secretary will be glad to give any further information as to details.

J. T. Clapham,
8, Homefield Road, Captain,

Wimbledon, S. W. 19. Secretary,

May, 1918.

30
EOYAL ARMY MEDICAL CORPS CENTRAL MESS FUND.

Summary op Peocebdings of a Meeting of Committee helc at the Royal Army Medical

College on April 29, 1918.

Present :
Lieut. -Col. D. Harvey, C.M.G., representing London, in the Chair.
Major W. A. Ward, representing Aldershot.
Capt. H. S. Dickson, representing Woolwich.

(1) The Minutes of the Meeting of November 14, 1917, were read and confirmed.

(2) The Accounts and Report for the year 1917-18 were examined and adopted unanimously.

(3) A letter was considered from Mess President, Depot, Royal Army Medical Corps, Blackpool,
stating that a Mess was to be opened in Blackpool, with a branch in camp at Squires Gate
during the summer, and asking for a grant of £50 in aid of formation expenses. »

(4) The question was considered of continuing the grant to the Aldershot Mess for
maintenance purposes. Major Ward said the number of dining members had not increased
since the original grant was made, a year ago, and that the funds available were quite inadequate
for the maintenance of the Mess, apart from the help given by the Central Fund. The furniture,
etc., of this Mess belongs to it and is not repairable by Government. The Committee considered
that it was most desirable that the Mess property be kept in proper order and sanctioned a grant
of £5 a month, payable by quarterly instalments in advance, for the year beginning April 1, 1918.

(5) The Hon. Secretafy of the Aldershot Mess reported that, at present, there were sufficient
means available for helping ]\rrs. Stacey, widow of the late Mess waiter, Mr. George Stacey.

(6) The Hon. Secretary of the London Mess stated that as regards the collection of heads
which Lieut. -Col Sir J. S. Rogers had presented to that Mess there was no present opportunity
of their being brought from Egypt.

(7) The Hon. Secretary having reported that there would probably be some surplus cash
available for investment, it was resolved that the Chairman and Honorary Secretary be
empowered to invest any available cash surplus, over and above the necessary balance at the
bank, in either five per cent National War Bonds, five per cent National War Loan 1924/47
and in any new loan which may be issued, as may be considered most desirable by Messrs. Holt
and Co. The Bonds to be iield, as before, by Messrs. Holt and Co. on behalf of the Fund.

(8) Payment of the audit fee to Mr. E. T. Ganu was sanctioned.

J. T. Clapham,
3, Homefield Road, Captain,

Wimbledon. Hon. Secretary.

AUXILIARY ROYAL ARMY MEDICAL CORPS FUNDS.

The usual Quarterly Meeting of the Committee was held at 11, Chandos Street, W. 1, on
July 12. There were present : ]\Iajor Maclean in the Chair, several members, including Major-
Gen. T. H. Goodwin, Director-General Medical Services, the Hon. Treasurer and the Hon.
Secretary.

From the Benevolent Branch for the relief of children of Ofificers of the Auxiliary Royal
Army Medical Corps, who died as a result of the present war, grants were made in three
cases. The amount granted was £176.

Grants from the Relief Branch for the relief of the widows and orphans of the Rank and
File of the Auxiliary Royal Army Medical Corps were also made.

Subscriptions and applications for relief from either Branch should be made to the Hon.
Secretary of the Auxiliary Royal Army Medical Corps Funds.
11, Chandos Street,

Cavendish Square, W. 1.

MEMORIAL TO LIEUT.-COL. H. MOORE, D.S.O., M.C.,
ROYAL ARMY MEDICAL CORPS.

A NUMBER of the friends and pupils of the late Lieut. -Col. Henry Moore, M.C., D.S.O.,
Royal Army Medical Corps, have decided to raise a Fund to perpetuate his memory by endowing
a bed under his name in the Royal City of Dublin Hospital, where he spent the greater part of
his professional life as student, house surgeon, and visiting surgeon. Would those willing to
assist kindly communicate with Mr. G. Jameson Johnson at the hospital.

ROYAL ARMY MEDICAL CORPS COMFORTS AND
PRISONERS' OF WAR FUND.

(Official Care Committee becognizkd by the War Office for the Royal Army

Medical Corps.)

The following is a second list of contributions from companies and units at home and
abroad to the Prisoners of War Fund received up to the end of April, 1918. It is hoped to
publish further lists at an early date.

Information has recently been received that a large number of British Prisoners of War
arrived at a certain camp all wounded, but the narrator adds that thanks to parcels from home,
however, they were well fed and not forced like other prisoners to live on horse-chestnut soup
and almost inedible bread.

This news, coming as it does from an independent source, gives us good hope that the parcels
for all branches of the British Army, including the Royal Army ^ledical Corps, are regularly
received , and this is borne out by the letters coming to the Ladies' Committee from the men
themselves and from their relatives.

R.A.M.C. College, E. M. Wilson,

Giosvenor Road, London, S.W. 1, Hon. Treasurer, R.A.M.C. Comforts

Jtcne 17, 1918. and Prisoners of War Fund.

SECOND LIST.

List of Companies and Units, at Home and Abroad Contributions to Prisoners op

War Fund in 1918.

April.

No. 6 Company R.A.M.C. and
Detachments

R.A.M.C, Netley..

No. 2 Company, Aldershot

12 and 34 Companies, Woolwich

43rd Field Ambulance . .

111th Field Ambulance . . 100 fr

4th Cavalry Field Ambulance .

4th Northern General Hospital
Lincoln . .

38th Field Ambulance . .

Rugeley Camp

1st and 2nd Training Brigades,
Blackpool

1st Training Battalion, Blackpool

2ndTraining Battalion, Blackpool

R.A.M.C. Detachment, South-
ampton Docks . .

20th Company, Tidworth

Sports Account, Blackpool

2,'lst Wessex Field Ambulance. .

l/4th South Lancashire Regt. . .

3rd Training Battalion, Blackpool

90th Field Ambulance . .

2/2nd West Riding Field Ambu-
lance

134tli Field Ambulance . .

26th Field"Ambulance . .

P.O.W. Hospital, Lichfield

Regimental Institutes, Blackpool

10th General Hospital . . . .

l/3rd Highland Field Ambu-
lance 200 fr.

2/lst London Field Ambulance . .

2/3rd Wessex Field Ambulance . .

Brd Casualty Clearing Station . .

Malta Detachments

£ s. d.

11th Stationary Hospital, France
75 11 9 42ud Field Ambulance . .

20 0 0 54th Field Ambulance . .

10 0 0 G2nd Casualty Clearing Station..

30 0 0 14th Stationary Hospital ^ . .

40 0 0 5th General Hospital . . . .

3 13 8 129th Field Ambulance . .

4 0 0 10th Field Ambulance . .

Military Hospital, Rugeley
25 0 0 51st Highland Division 8b0fr. andlO

20 0 0 22nd General Hospital . .

5 0 0 No. 10 Stationary Hospital

50th Stationary Hospital
S 18 10 2/3rd East Lancashire Field Am-

5 0 0 bulance .. .. 1,000 fr.

5 0 0 12th Casualty Clearing Station. .

26th General Hospital . .
10 0 0 104th Field Ambulance (450 fr.)

2 2 0 1st Southern General Hospital

9 13 6 (T.F.)

10 10 0 101st Field Ambulance (100 fr.)
9 4 11 ' 12th St. Louis, U.S.A. General

5 0 0 Hospital 7 0 0

10 10 0 . 33rd Field Ambulance (580 f r. ) . .

36th Casualty Clearing Station. . 5 0 0

10 0 0 l/3rd East Lancashire Field Am-

5 0 0 bulance . .

4*0 64th Casualty Clearing Station

50 0 0 25th Ambulance Train . .

300 0 0 52nd General Hospital . .

39 8 11 132nd Field Ambulance 700 fr. and 4 0 0

43rd Casualty Clearing Station

7 7 4 (550 fr.)

18 6 8 56th Casualtv Clearing Station

9 5 0 " (500 fr.i

14 0 0 Craig Lockhart Hospital, Officers 6 0 0

15 0 0 ! No. 4 Field Ambulance (300 fr.)

12 3

16 16

5 5

13 7

EOYAL ARMY MEDICAL COLLEGE.

LIST OF BOOKS ADDED TO THE LIBRARY DURING THE MONTHS OF
APRIL, MAY AND JUNE, 1918.

Title of Work and Author

Date

How obtained

An Index of Differential Diagnosis of Main Symptoms. '

Edited by Herbert French, M.A., M.D.
Lectures on Massage and Electricity in the Treatment of

Disease. By T. S. Dowse, M.D.
An Index of Treatment. By Various Writers. Edited

by Robert Hutchison, M.D., and James Sherren,

F.R.C.S.
Physiological Abstracts. Edited bv W. D. Halliburton.

Vol. i., No. 1 to Vol. iii.. No. 3.
Anti-Malaria Work in Macedonia. By W. G. Willoughby

and Louis Cassidy
The Essentials of Chemical Physiology. By W. D.

Halliburton, M.D., F.R.S.
American Addresses. By Sir Berkeley Movnihan, M.S.,

F.R.C.S.
Handbook of Operative Surgery. By W. I. de C. Wheeler,

B.A., M.D.
Field Service Notes for Royal Armv !Medical Corps. By

Colonel T. H. Goodwin, A. M.S.
Surgical Therapeutics and Operative Technique. By

E. Doyen. English Edition by H. Spencer Browne.

Vol. ii. .
Analytical Chemistry. By Treadwell and Hall. Vol. i.
How to Treat by Suggestion. By E. L. Ash, M.S.
The Rhymes of a Red Cross Man. By R. W. Service . .

Who's Who

The New Hazell Annual and Almanack
Malingering. By Sir John Collie . . . . . .

Malingering. By Jones and Llewellyn

Hygiene and Public Health. By Parkes and Kenwood . .

Laboratory Studies in Tropical Medicine. By Daniels and

Newham
Epidemics Resulting from War. By Dr. F. Prinzing . .
The Drink Problem of To-Day. Edited by T. N. Kelynack
Construction and j\lanagement of a General Hospital. By

Donald Mackintosh

On the Road to Kut. By Black Tab

At Suvla Bay. Bv John Hargrave ..

The Wounded French Soldier. By D. C. Calthrop

Lord Lister. By Sir R. J. Godlee, Bt

Emergency Surgery. By John W. Sluss, A.M., M.D. ..

Tlie Edinburgh Review, April . .

Tropical Diseases. By Sir P. Manson, G.C.M.G. . .

Ambulance No. 10. By L. Buswell . .

Minor Surgery and Bandaging. By M. Davies (Heath and

Pollard)
The Practitioner's Pocket Pharmacology and Formulary.

By L. Freyberger
Memoranda on Army General Hospital Administration.

Bv Various Authors. Edited by Lieut. -Col. P. Mitchell,

M.D.
The Causation of Sex in Man. By E. R. Dawson
Librarv of Congress. Report for the^Fiscal Year ending

June 30, 1917

3rd 1917 Library Grant.

I 1906 I
7th ! 1917

I 1916- 18s

1918
9th 1916

1917
3rd ! 1918

1918

I 1916 :

I 1914 :

I 1918 ■

1918 ,

I 1918 I

2nd i 1917 I Editor, Journal.

I 1917

6th
4th

4th
6th
16th

2nd

1917
1918

1916
1916
1916

1917
1916
1916
1917
1917
1918
1917
1916
1917

1917

1917
1917

List of Books added to the Library — Continued.

Title of Work and Author

Medical Research Committee. Reports of the Air Medical
Investigation Committee. No. 1. The Oxygen Needs
of Flying officers
No. 2. I. — Medical Aspects of High Flying

II. — Procedure for Testing the Eflects of
Oxygen Want
III.— Observations on the Cardio-vascular and
Nervous System of Successful Pilots
No. 3. Flying Stress
Medical Research Committee. Report to the Committee
on War Nephritis. By H. MacLean, M.D., D.Sc, Hon.
Captain R.A.M.C.
Reports of the Anaerobe Committee. No. 1. The Demons-
tration of Anaerobes in Wounds of recent date
Reports of the Special Investigation Committee on Surgical
Shock and Allied Conditions. No. 4. Memorandum
on Blood Transfusion. By Captain Oswald H.
Robertson, M.D.R.C, U.S.A.
Reports of the Chemical Warfare IMedical Committee : —
No. 1. Notes ou the Pathology and Treatment of the

Effects of Pulmonary Irritant Gases
No. 2. The Historical Effects Produced by Gas

Poisoning and their Significance
No. 3. The Symptoms and Treatment of the late

Effects of Gas Poisoning
No. 4. Polycythaamia after Gas Poisoning and the
Effect of Oxygen Administration in Chambers in
Treatment of Chronic Cases
No. 5. The Reflex Restriction of Respiration after

Gas~ Poisoning
No. 6. Investigations into the Reaction of the Blood
after Gas Poisoning, and the Results of the Ad-
ministration of Saline and other substances. The
Effects of Bleeding and of the injection of Calcium
Chloride
No. 7. Changes observed in the Heart and Circula-
tion, and the General After Effects of Irritant Gas
Poisoning
Military Overcrowding and the Meningococcus Carrier.

By Capt. J. A. Glover, M.D., D.P.H., R.A.M.C.
Memoranda Supplementary to IMedical Research Com-
mittee, Special Report Series, No. 8

No. 2. A Comparison of Patients with Valvular and
Non-valvular Affections. By Thomas Lewis, M.D.
Journal of the Royal Naval Medical Service, April
Catalogue of the War Office Library. Part III (Subject
Index). Sixth Annual Supplement (January to Decem-
ber. 1917). Compiled by P. J. Hudleston
Year Book of the Royal Society

Britsh Medicine in the War, 1914-1917. Essays, &e.,
Collected out of the British Medical Journal, Agril to

October, 1917

The Systematic Treatment of Gonorrhoea. By Capt.

N. P. L. Lumb, R.A.M.C

Journal op the Royal Army Medical Corps, vol. viii,
1907, to vol. xxix, 1917 (unbound)

A Text-book of Radiology (X-Rays). By E. R. Morton,
M.D

Meteorology of Australia. Results of Rainfall Qbserva-
vations made in Queensland. By H. A. Hunt . .

The Geographical Journal, August, 1917, to June, 1918

Edition

1918

1918
1918

1918

1918
1918
1918

1918
1918

1916

1918
1917

1918
1918

How obtaini>(l

Medical Research
Committee.

The Editor.
War Office.

1907-17

2ud I 1918

1914

1918 I Royal Society.
1917 i Presented by Surg.-
' Gen. Sir D. Bruce,
' K.C.B., P.R.S.
> Presented by the
Author.
Presented by Surg.-
Gen.W. S.M.Price,
A. M.S.
Presented by the

Author.
Presented by Major
L. Lanyon Ow6n,
R.A.M.C.
Presented by Col.
1917-18 I R. J. S. Simpson,
C.B., C.M.G.,

A. M.S.

EXCHANGES, &c.

The charge for inserting Notices respecting Exchanges in the Royal Army
Medical Corps is 5/- for not more than five lines, which should be forwarded by
Cheque or P.O.O., with the notice, to Messrs. G. STREET and CO., Ltd.,
8, Serle Street, London, W.G., not later than the 22nd of the month.

lRoticc0.

EDITORIAL NOTICES.

The Editor will be glad to receive original communioations upon professicnal subjects,
travel, and personal experiences, etc. He will also be glad to receive items of news and
information regarding matters of interest to the Corps from the various garrisons, districts,
and commands at home and abroad.

All Buoh CommunloatlonB or Articles accepted and publlshad In the "Journal
of the Royal Army Medical Corps" vrlll (unless the Author notified at the time of
Bubnaission that he reserves the copyright of the Article to himself) become the
property of the Library and Journal Committee, srho will exercise full copyright
poDvers concerning such Articles.

Matter intended for the Corps News should reach the Editor not later than the 15th of
each month for the following month's issue. Notices of Births, Marriages, and Deaths are
inserted free of charge to subscribers and members of the Corps. All these communioations
should be written upon one side of the paper only ; they should by preference be type-written ;
but, if not, all proper names should be written in capital letters (or printed) to avoid mistakes,
and be addressed ; The Editor, " Jodbnal of the Royal Abmy Mbdical Cobps," 324, Adastral
House, Victoria Embankment, E.G. 4.

The following publications have been received : —

British : St. Bartholomew's Hospital Journal, Guy's Hospital Gazette, The Journal of State
Medicine, The Practitioner, Liverpool School of Tropical Medicine, The Hospital, Tlie Medical
Press and Circular, Journal of the United Service Institution of India, The Indian Medical
Gazette, The Quarterly Journal of Medicine, The Jotirnal of Tropical Medicine and Hygiene,
Surgery, GyncBCology, and Obstetrics, Public Health, The Medical Journal of Australia, TJie
Royal Engineer's Journal, Proceedings of the Royal Society of Medicine, Edinburgh Medical
Journal, Abstracts of Bacteriology, The British Journal of Ttiberculosis, The Army Service Corps
Journal, The Medical Revieio.

Foreign : The Military Surgeon, Bulletin de I'Institiit Pasteur, Bulletin of the Johns Hopkins
Hospital, Bulletin de la Soci^ie de Pathologic Eo'otique, L'Ospedale Maggiore, Office Biternational
d'Hygiine Publique, Archives Midicales Beiges, Giornale di Medicina Militare, Annali di
Medicina Navale e Coloniale, Archives de Mideci'ne et Pharmacie Navales, Colonies et Marine,
Norsk Tidskrift for Militaertnedicin, United States Department of Agriculture.

A free issue of twenty-five reprints will be made to contributors of Original Communications,
and of twenty-five excerpts of Lectures, Travels and Proceedings of the United Services
Medical Society.

Any demand for reprints, additional to the above, or for excerpts, must be forwarded at
the time of submission of the article for publication, and will be charged for at the following
rates, and additional copies at proportionate rates : —

Extra for Oovbrs for Rkprints

NUMBKR
OF

Paobs

Cost
OF Rkpri

NTS

Cost ok
EXCERPTS^

Uehrists

As Journal,

Printed on

Front

As Journal,

Plain,
Unprinted

Cheaper

Paper,

Printed on

Front

Cheaper
Paper,
Plain,

Unprinted

£ s.
0 2
0 5
0 8

d.
9
0
3

£ s. d.
0 12
0 2 3
0 3 11

s. d.

j..

s. d.
1 1

s. d.
3 10

s. d.
0 9

0 3
0 6
0 10

4
0
6

0 15
0 2 9
0 5 0

I 4 10

1 6

4 4

0 11

50 1

0 4
0 7
0 13

6
6
3

0 1 10
0 3 0
0 5 10

- 6 0

2 1

4 10

1 2

100

0 6
0 10

0 18

0
0
6

0 8 1

0 4 10
0 7 6

I 7 10

3 11

6 7

2 5

200 1

0 9

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1 6

6
0
0

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0 9 8

10 10

7 6

9 0

4 10

These are not arranged as Reprints, but appear precisely as in the Journal with any other matter that
may happen to appear on the tirat and last pages of the particular excerpt ordered.

Cases for Binding Volumes. — Strong and useful cases for binding can be obtained from
the publishers at the undermentioned rates : —

Covers, 2s. 6d. net ; binding, 2s. 6d.

These charges are exclusive of cost of postage.
In forwarding parts for binding the name and address of sender should be enclosed in parcel.

The above figures are subject to 25 pep cent increase.

All A2)plications for Advertisements to he made to —

G. STEEET & CO., Ltd., 8, Seble Steeet, London, W.C.

The back outside cover is not available for advertisements.

MANAGER'S NOTICES.

The JouBNAL OF THE BoTAL Abht Medical Cobps is published monthly, six montha
constituting one volume, a volume oommenoing on 1st July and 1st January of each year.

The Annual Subscription is £1 (whioh includes postage), and should commence either
on 1st July or 1st January ; but if a subscriber wishes to commence at any other month
be may do so by paying for the odd months between 1st July and 1st January at the rate
of Is. 8d. (one shilling and eightpence) per copy. (All subscriptions are payable in advance.)

Single copies can be obtained at the rate of 2s. per copy.

The Corps News is also issued separately from the Journal, and can be subscribed for at
the rate of 2s. (two shillings) per annum, including postage. Subscriptions should commence
from 1st July each year ; but if intending subscribers wish to commence from any other
month, they may do so by paying for the odd months at the rate of 2d. per copy. (All
subscriptions are payable in advance.)

Officers of the Royal Army Medical Corps possessing Diplomas in Public Health, etc., are
kindly requested to register their special qualifications at the War Office. Letters of
complaint are frequently received from officers stating that their special qualificationB
have not been shown in the Distribution List which is published as a supplement to the
Journal in April and October of each year. As, however, the particulars of this list are
supplied from official sources, officers are reminded that unless the possession of Diplomas,
etc., has been registered at the War Office, no entry of such qualifications can be recorded
in the Distribution List-
Letters notifying change of address should be sent to the Hon. Manager, " Joarnal
of the Royal Army Medical Corps," 25, Adastral House, Victoria Embankment, B.C. 4,
and must reach there not later than the 20th of each month for the alteration to be
made for the following month's issue.

It is requested that all Cheques or Postal Orders for Subscriptions to the Journal,
Corps News, Reprints, etc., be crossed " Holt & Co.," and made payable to the " Hon.
Manager, Journal R.A.M.C.," and not to any individual personally.

All communications for the Hon. Manager regarding subscriptions, etc., should be
addressed to

The Hon. Manaqeb,

" JOUBNAL OP THE BO^AL ABMT MbDICAL COBFS,"

25, Adastbal House, Victobia Eubanement, E.C.4.

<K'^

Advc'f iioaciuc Ills .

^ Syrupus

Hypophosphitum Comp.

FELLOWS

It is not unusual to meet the claim that other prepara-
tions are "just as good " as FELLOWS, but no one has
met the preparation which rightly claimed to be better
than FELLOWS. For over fifty years FELLOWS*
SYRUP has maintained its supremacy as the standard
preparation of the Compound Hypophosphites.

Reject

Cheap and Inefficient Substitutes
Preparation* "Just as Good**

VALENTINE'S
MEAT - JUICE

In Typhoid and other Fevers, Extreme
Exhaustion, Critical Conditions, Before
and After Surgical Operations, when
Other Food Pails to be Retained,
Valentine's Meat *• Juice demon-
strates its Ease of Assimilation and
Power to Restore and Strengthen.

Clinical Reports from Hospitals and General Practi-
tioners of Europe and America posted on applicatlout

For sale by Earopean and American Chemists and
Druggists.

VALENTINE'S MEAT^JUICE CO.,

Richmond, Virginia, U. S. A.

B190

CONTENTS.

Originaii Communications. p^^.

Toxic Action of Carbonic and other Weak Acids on the MeniDgococcus. By J. A.

Shaw-Mackbszib, M.D.Lond. . . . .1

The Symptoms of Acute Cerebellar Injuriea as Observed in Warfare. By
Lieutenant-Colonel Gordon Holmes, K.A.M.C. . . .12

Observations on 250 Cases of Gunshot Wounds of the Peripheral Nerves. By

Major C. Noon, E.A.M.C. . . . .39

The Prophylaxis of Malaria. By Colonel G. T. Eawnslby, C.B., C.M.G.,
Lieutenant- Colonel R. A. Cunningham, R.A.M.C, and Captain J. Warnock,
E.A.M.C .60

ClilNIOAL AND OTHER NOTBB.

Anaesthetics in the Field. By Captain W. R. H. Hbddy, E.A.M.C. (T.) . . 76

Notes on the Treatment of Amoebic Dysentery with Emetine and Bismuth Iodide.

By Captain A. C. Lambert, E.A.M.C. . . . .79

Notes on the Treatment of Subtertian Cerebral Malaria with Quinine and Galyl.
By Major A. W. Falconer, E.A.M.C, and Captain A. G. Anderson,
E.A.M.C 83

Cerebrospinal Fever : Notes on 251 Cases treated at the Salisbury Isolation
Hospital. By J. E. Gordon, M.E.C.S., L.E.C.P. . . . .90

fesviEWs ........... 95

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